™ MEDICAL .SCHOOL LI ISMAM.1T Digitized by the Internet Archive in 2016 https://archive.org/details/journalofmedical28unse THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY PUBLISHED MONTHLY UNDER THE DIRECTION OF THE BOARD OF TRUSTEES Volume XXVIII. January, 1931— December, 1931 Publication Committee : Drs. Henry C. Barkhorn, Edward J. Ill, Linn Emerson J. Bennett Morrison 14 South Day Street, Orange, N. J. ; ; , ’ ; Editor:,*,- » TP/ Henry G. Reik, M.D.v'F.A.C.S, INDEX Address, President’s Annual 539 President’s to House of Delegates Aug. Sup. 1 Advertising, False and Misleading Aug. Sup. 8 Aug. Sup. 47 American College of Physicians, Report of Meeting 51.3 American Federation of Hard of Hearing 953 American Medical Association Convention 666 Delegates’ Report of Aug. Sup. 36 American Physiotherapy Association; Letter from Dr. Harold D. Corbusier 63 Annual Conference, Secretaries and Reporters of County Societies 956 ANNEAL MEETING— Assessment of Dues Aug. Sup. 18 House of Delegates Report Aug. Sup. 1-59 Preliminary Program of 435-441 Scientific Sessions, Report of Aug. Sup. 56 Section of Ophthalmology, Otology and Rhinolaryn- gology , Aug. Sup. 59 Section on Pediatrics Aug. Sup. 61 Section on School Physicians Aug. Sup. 62 Transactions of Aug. Sup. 1-86 Woman’s Auxiliary Aug. Sup. 63-86 Annual Report of Editor and Executive Secretary .Aug. Sup. 6 Asbury Park Convention 579 AUTHORS OF ORIGINAL ARTICLES— Adams, J. K.: Discussion of Fractures 12 What Is Wrong with the Fracture Situation? 3 Aitken, Frank J. T. : A Group of Endocrine Cases 470 Altschul, F. J. : Fusospirochetal Disease of the Lung.. 834 Arlitz, William J. : Discussion of Fractures 10 Asher, Maurice: Discussion of Duodenal Tube Drainage of the Biliary System 814 Avidan, Maurice S.: Discussion of Fractures 11 Baker, Charles Frederick: Duodenal Stasis 1 Bancroft, Frederic W. : Thrombosis and Embolism 619 Barbarito, William N. : Discussion of Duodenal Tube Drainage of the Biliary System 814 Barkhorn, Henry C. : Discussion of Acute Mastoid Dis- ease 26 Our County, Presidential Address to Essex County Medical Society 900 Report of Publication Committee Aug. Sup. 2 Beling, C. C. : Report of Judicial Council Aug. Sup. 17 Belk. William P. : Discussion of Fusospirochetal Dis- ease of the Lung 849 Blanchard, Kenneth: Discussion of Changes in Human Rickets After Viosterol Therapy 22 Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Bland, P. Brooke: Leukorrhea 489 Bowen, D. C. : Health Department Growth in New Jersey j 196 State Health Laws 59 Bowers, Anna Mae: The Future of Freud 52 Bowles, Harry IT. : Medical Ethics 35 Bradshaw, John Hammond: A Visit to the Royal Vic- toria Hospital, Montreal 715 C’est Formidable L’ Opinion Publique 717 Hurry, Hurry, Hurry! 952 Lowering of the Standard of Ethics 53 Medical Societies 581 More Health Ethics 143 Patients Must Not Be Neglected 432 Recent Visit to the Grenfell Mission on the Labrador 864 Success 867 The Physicians in Holy Writ 252 Uphold Honor of the Profession 494 “Who Steals My Purse Steals Trash” 359 Bronner, Augusta F. : The Future of Freud 52 Brown. Harvey: Discussion of Pedographic Impressions in School Children 930 Burton, Opitz R. : Clinical Significance of High and Low Blood Pressure 302 Caffey, John: Changes in Human Rickets After Vios- terol Therapy 21 Discussion of Changes in Human Rickets After Vios- terol Therapy 22 Campbell, William: Advantages of General Anesthesia in Tonsillectomy < « , « *..., 29 Church, Franklin H.: Forcible Extension in an Anky- losed Joint ! . i '. .. 9‘l4 Cone, Ralph S.: Requiem to the Unknown Soldier ... 142 The Bell Buoy ^ ^ . 577 1 The War Nurse’s Story 1 ... .^. 14± Corbusier, Harold D : American Physiotherapy Asso- ciation , 6^* Corson, E. S. : Phlebitis 1*2 Corwin, Theodore W. : Discussion of Tonsillectomy 30 Cosgrove, Samuel A.: The General Practitioner and Obstetrics 545 Coughlan. Ella: Discussion of Pedographic Impressions in School Children 930 Craster, Charles V.: A Skin Test for Whooping Cough 236 Danzis, Max: Discussion of Biliary Tract Disease _ 797 Discussion of Duodenal Tube Drainage of the Biliary System 815 Honor to Max Danzis • • 276 Darlington, E. P. : Discussion of Symposium on Public Health Work 207 Davidson, Harold S. : Diabetes Mellitus and Throm- bo- angiitis Obliterans in the Same Patient 570 Recurring Postoperative Parotitis 85 Deaver, J. Montgomery: Discussion of Biliary Tract Disease 299 Deaver, John B.: Surgical Aspects of Biliary Tract Disease 295 De Meritt, C. L. : Medical Possibilities of Sea Water.. 706 The Acute Abdomen ;• 407 Doane, Joseph C. : What the Present Day Public Thinks of the Medical Profession 648 Donaldson, Walter F. : A Romance of Paternalism 587 Doody, William: Child Guidance 595 Downs, R. I. : Publicity, a Remedy for Many Society Problems 959 Dublin George J. : Common Conditions in Industrial Ophthalmology 704 Dunnington. John Hughes: Clinical Management of Heterophoria 919 Discussion of Ocular Muscle Abnormalities 927 Eagleton, Wells P. : A Doctor’s Confession of Faith. . 237 Ellis, William J. : Development of Public Welfare Work 187 Ely, Lancelot: Report of Committee on Scientific Work Aug. Sup. 2 Emerson, Linn: Combined Orthoptic and Operative Treatment of Convergent Squint in Young Children 923 Discussion of Acute Mastoid Disease 27 Discussion of Ocular Muscle Abnormalities 926-7 Ewing, Harvey M. : Discussion of Cardiac Irregulari- ties and Silent Mitral Stenosis 912 Fanburg. S. J. : Fungus Infections of the Skin 92 Finkelstein, A. S. : Discussion of Whooping Cough 100 Treatment of Whooping Cough 96 Finkler. Rita S. : The Female Sex Hormone 766 Fish, Clyde M.: New Method of Outlining the Heart, Its Chambers and Great Vessels 817 Floyd, Rolfe: Treatment of Bright’s Disease 552 Fowler, Robert H. : Discussion of Acute Mastoid Dis- ease 26 Discussion of Tonsillectomy 31 Tonsillectomy Under Local Anesthesia 27 Gamon. Robert S. : Is Group Medical Publicity Ethical? 961 Gardam, Joseph William: Statistical Study of Diph- theria in Newark 626 Gerber, Louis J. : Radiographic Diagnosis of Gall-Blad- der Pathology 829 Gerendasy, J. : Practical Gastro-Enterology 768 Giglio, A. S. V.: Tonsillectomy by Diathermy 77 1 Goldstein, H. H. : Foreign Body in the Urinary Blad- der 709 Useful Irrigating Fluid for Septic Wounds 492 Goldstein, Hyman I.: Discussion of Cardiac Irregu- larities and .Silent Mitral Stenosis 913 Hereditary Epistaxis 309 Gowen, Cecil H. : Bacteriologic Study of Chronic In- fectious Arthritis 38 Gray, John W. : Bacteriologic Study of Chronic Infec- tious Arthritis 38 Griffin, Guy B.: Liver Cysts 337 Gross, Max: Review of Recent Literature on Thrombo- angiitis Obliterans 571 Hagertv, John F. : A Case of Pseudo-Hermaphroditism 899 Discussion of Fractures 9 Discussion of Symposium on Public Health Work 208 Memorial Tablet to Dr. O. H. Sproul 110 Haigh, G. W. : Medical Service of the Future 115 Hallinger, E. S. : Sinusitis 475 Hartman. J. C. : Obstetric Mortality 31 ^Ifij’twpll, Johiji Continued Education of the « . I)bc\or . i 639 HeM>\ WillWn : . Tb’e! Jrufure of Freud 52 Heller,' George: ‘ PreVerftton of Measles 617 Heller. N. B . : Alc^ojic^ fse^do- Pellagra 467 Hermnntt/ Jonf\ «H*. : -Liver. \Gy?ts 337 ; IJerrn?an, W. 4«G- i $is£fts&it>ij[ of Fusospirochetal Dis- * ' base of* the *Ltmg •*.•.*... .* 849 INDEX Fusospirochetal Disease of the Lung 834 Uterine Hemorrhages Radiologically Considered 819 Heyd. Charles Gordon: The Physician’s Economic Con- tribution to the Community 258 Heyman, Arthur: Discussion of Malnutrition in Chil- dren 211 Hubbard, H. V. : Discussion of Ocular Muscle Abnor- malities 926 Discussion of Tonsillectomy 30 Overlapping the Rectus Muscles for Correction of Strabismus 915 Huberman, John H. : Value of Blood Sedimentation Test in Gynecology 403 Hull, Donald B. : Discussion of Pedographic Impres- sions in School Children 930-931 Pedographic Impressions in School Children 928 Hummel, E. G. : Discussion of Whooping Cough 100 Hyman, Albert S. : Myocardosis; the Failing Heart of Middle Life 831 Treatment of Acute Coronary Thrombosis 296 111, Edward J. : Society for Relief of Widows and Or- phans of Medical Men of New Jersey 69 Ireland, Allen G. : Discussion of Pedographic Impres- sions in School Children 930-931 Discussion of the Physician’s Part in the Training Irvin, John S. : Public Relations as a Specific 959 Jack, H. Wesley: Factors in the Early Diagnosis and .. Treatment of Fractured Skulls 603 Jaffin, A. E.: Discussion of Cardiac Irregularities and Silent Mitral Stenosis 912 Discussion of Duodenal Tube Drainage of the Biliary System 814 James, Bart M. : Common Diseases of the Oral Mucosa 563 Johnson, F. C. : Discussion of Diet in Eczema of In- fants 223 Discussion of Non-Pathologic Heart Murmurs in Children 103 Johnson, V. Earl: Modern Treatment of Varicose Veins 229 Kahrs, Grace M. : The Physician’s Part in the Train- ing of Teachers 932 Kelley, Charles B. : Discussion of Symposium on Pub- lic Health Work 206 Kerley, Charles Gilmore: Discussion of Gastro-Intes- tinal Disorders 20 Gastro-Intestinal Disorders 14 Kessler, Henry H. : Discussion of Fractures 11 State Department of Labor in Relation to the Public and Medical Profession 200 Kildufle, Robert A.: The Anemia of Pregnancy 341 Kiley, John E. : Occupational Dermatitis 613 Kinch, Frederick A.: Discussion of Pedographic Im- pressions in School Children 931 Discussion of the Physician's Part in the Training of Teachers 936 Kipp, Charles J. : Memorial Tribute to Dr. Charles J. Kipp 275 Klein, Edward C., Jr.: Ruptured Gastric Ulcer 412 Kramer, David W. : Circulatory Disturbances in the Extremities of Diabetics 560 Krauss, F. I. : Diet in Eczema of Infants 217 Discussion of Eczema in Infancy 228 Discussion of Essentials in Infant Feeding 216 Discussion of Gastro-Intestinal Disorders 20 Discussion of Integration of the Child 109 Discussion of Malnutrition in Children 211 Discussion of Whooping Cough 99 The Practitioner’s View of Medical Economics 743 Kuder, Joseph M. : Local County Medical Society Publicity %2 Kummel, Max: Medicolegal Aspects of Disability in Industrial Lead Poisoning 327 Lamson. William J. : Discussion of Pedographic Im- pressions in School Children 931 Lathrope, George H. : Discussion of Value of Duodenal Tube Drainage of the Biliary System 813 Etiology, Diagnosis and Treatment of Peptic Ulcer.. 344 Some Difficulties of the Asthma Problem 684 Levy, Julius: Child Hygiene 694 Discussion of Integration of the Child 109 Discussion of Whooping Cough 99 Influence of Public Health Activities on Medical Practice 193 Lippincott, A. Haines: Presessional Report of the Wel- fare Committee 438 Regular Report of the Welfare Committee. .Aug. Sup. 27 Littwin, Charles: Discussion of Ocular Muscle Abnor- malities 926 Lyon, B. B. Vincent: Discussion of Duodenal Tube Drainage of the Biliary System 815 Value of Duodenal Tube Drainage of the Biliary Sys- tem in the Treatment oi Disease and Disorders of the Liver 799 McBride, Andrew F. : Discussion of Fractures 14 Discussion of Symposium on Public Health Work... 206 McCauley, F- J. : Discussion of Eczema in Infancy 228 Eczema in Infancy 223 McGuire, James J. : Annual Report ol Board of Medical Examiners Aug. Sup. 29 Violations of Medical Practice Act 63 McKiernan, R. L. : Foreign Body in the Urinary Blad- der 709 McLean, Stafford: Discussion of Changes in Human Rickets After Viosterol Therapy 21 Maliniak, Jacques W. : Plastic Surgery 679 Marsh, Elias J. : Abell Commission Report 62 Discussion of Ocular Muscle Abnormalities 926 Treasurer’s Annual Report Aug. Sup. 19 Treasurer’s Presessional Report 496 Martin, J. W. : Discussion of Fractures 13-14 Relation of Traumatic Surgery to Industry 6 Marcus, Joseph H. : Clinical Evaluation of a Concen- trate of Vitamins A and D S50 Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Marcus, Joseph M. : The Gastro-Intestinal Patient 90 Mark, Joseph S. : Differential Diagnosis of Lead Poi- soning 334 Prevention and Control of Lead Poisoning in In- dustry 773 Marvel, Philip, Jr.: Cardiac Irregularities 903 Discussion of Cardiac Irregularities and Silent Mitral Stenosis 913 Mengel, Willard G. : Squint in Childhood and Its Ef- fect in Later Life 700 Miller, D. J. M. : Discussion of Non-Pathologic Heart Murmurs in Children 103 Morrison, J. Bennett: An Historical Sketch of Develop- ment of Preventive Medicine in New Jersey 731 Discussion of Fractures 10 Discussion of Symposium on Public Health Work.. 206 Newcomb, M. W. : Discussion of Pedographic Impres- sions in School Children 931 Nichols. Stanley H. : Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Discussion of Integration of the Child 109 Discussion of Non-Pathologic Heart Murmurs in Children 102 Nicholson, Percival: Discussion of Eczema in Infancy 227 Discussion of Essentials in Infant Feeding 217 Discussion of Gastro-Intestinal Disorders 20 Essentials in Infant Feeding 212 North, Harry R.: Finance and Budget Committee Re- Okin, Irving: Discussion of Nipn- Pathologic Heart Murmurs in Children 103 Non-Pathologic or Functional Heart Murmurs in Children 100 Orr, Thomas G. : Culture 581 Osmun, L. Cook: Councilor District Meeting 63 Paddock, Royce: The Dust and Bacterial Factors in Asthma 687 Pannell, W. L. : Some Oddities in Acute Mastoid Dis- ease 22 Parsonnet, Aaron E. : Myocardosis; The Failing Heart of Middle Life 831 Treatment of Acute Coronary Thrombosis 296 Parsons, William Barclay: Indications for Surgery in Diseases of the Thyroid 431 Patterson, Ross V.: Our Responsibility for Public Edu- cation Regarding Comparative Costs of Sickness... 585 Peacock, Robert: Discussion of Symposium on Pub.ic Health Work 207 The Doctor and the Law 203 Peer, Lyndon A.: Asthma from the Standpoint of the Rhinologist 692 Tube Flaps in Reconstructive -Surgery of the Face.. 86 Perlberg, Harry J. : A Few Thoughts in Therapy for Ailing Medical Practice Neither New Nor Official.. 960 Filler, Jacob: Treatment of Active Measles by Intra- muscular Injection of Recent Convalescent Whole Blood 340 Pinneo, Frank W. : Discussion of Fractures 10 Discussion of Symposium on Public Health Work... 206 Preliminary Report of Health and Accident and Automobile Insurance Committee 438 Regular Report of Health and Accident and Automo- bile Insurance Committee Aug. Sup. 34 Polevski, Jacob: Discussion of Cardiac Irregularities and Silent Mitral Stenosis 913 Discussion of Duodenal Tube Drainage of the Biliary System 815 Relation of Arteriosclerosis to Cardiac Pathology.... 762 Significance and Diagnosis of Silent Mitral Stenosis 910 Some Sources of Information and Misinformation in Cardiac Diagnosis 121 Pons, C. A. : Discussion of Fusospirochetal Disease of the Lung 849 Fusospirochetal Disease of the Lung 834 Quigley, F. J. : Discussion of Symposium on Public Health Work 207 INDEX Read, Hilton S. : Constipation 755 Danger Ahead in the Cathartic Habit 660 Reik, Henry O. : Automobiles More Deadly Than War 148 Discussion of Symposium on Public Health Work.... 207 Editorials (see list) Lighthouse Observations (see list) Presessional Report of Editor and Executive Secre- tary 439 Regular Annual Report of Editor and Executive Sec- retary Aug. Sup. 6 Reports to Welfare Committee 64, 65, 363 Reviews of Books for Collateral Reading: Biologic Basis of Human Nature — H. S. Jennings 145 Clinical Interpretations of Blood Examinations — Robert A. Kilduffe 433 Doctor and Patient — F. W. Peabody 360 Easier Motherhood — Constance L. Todd 433 Noguchi — Gustav Eckstein 778 Our New Progress — James Bayard Clark 361 Paris and All the World Besides — Robert M. Keeley 433 .Soviet Russia — William Henry Chamberlin 361 Women and Monks— Joseph Kalinikov ... . 361 State Medicine in England 246 State Medicine in France 354 State Medicine in Other Countries 427 Travel Talks, with Medical Observations 42. 135. ?16, 354, 427 Reissman, Erwin: Looking at the Facts in the High Cost of Medical Care 854 Rodman, E. W. : Consideration of the Causes of Diar- rhea 548 Rosenberg, L. Charles: Discussion of Essentials in In- fant Feeding 217 Discussion of Malnutrition in Children 212 Malnutrition in Children 208 Ross, William H.: Obligations of Professional Medical Service 159 Report of Governor Roosevelt’s Commission to De- vise a Public Health Program 508 The Open Hospital 51 Rothschild, Karl A.: One Year of Neurologic Service.. 47S Rubinow, S. : Some Thoughts on Medical Economics and Medical Practice 238 SchafF, Royal A.: Acute Perforation of Peptic Ulcers 417 Schapiro, Joseph: Discussion of Pedographic Impres- sions in School Children 931 Schiffmann. S. : Moses Maimonides — Physician and Philosopher 750 Schulte. Herbert A.: Treatment of Perforated Peptic Ulcer 421 Schwarz, Berthold T. D.: Short History of Diphtheria Eradication 529 Scott, James Ralph: Practical Management of Dia- betes 304 Sherman, A. Russell- Observations in the Vienna Eye Clinics 485 Sherman, E. S. : Discussion of Ocular Muscle Abnor- malities 926 Shope, Pierce: Refraction and Health 69 7 Silver, H. B. : Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Smith, Ellis: A Skin Test for Whooping Cough 236 Snedecor. S. T. : Discussion of Pedographic Impressions in School Children 930-931 Discussion of the Physician’s Part in the Training of Teachers 935-936 Sommer, George N. J. : Discussion of Symposium on Public Health Work 207 Impressions of Annual Conference of Secretaries of Constituent State Medical Associations, 1930 60 New Year Greetings 49 Presidential Address 539 Presidential Address to House of Delegates. . Aug. Sup. 1 Spencer, G. T. : Intradural Caudal Anesthesia 235 Sproul, O. IL: Memorial Tablet to Dr. O. H. Sproul... 110 Stalberg, Samuel: Discussion of Integration of the Child ! 109 Stern, Arthur: Discussion of Diet in Eczema of Infants 222 Discussion of Whooping Cough 99 Stewart, Walter B.: The Cult of Asklepios 603 Stewart, W. Blair: Report of American College of Physicians Meeting 513 Stokes, John II. : Preventing the Transmission of Syphilis 391 Stokes, S. Emlen: The County Society 114 Subin, Harry: High Lights in the Life of Robert Koch 342 Sullivan, George F. : Discussion of Ocular Muscle Ab- normalities 926 Talleson, H. M. : Are We Underpaid? 578 Taneyhill, Mrs. E. C. : Report of Field Secretary Aug. Sup. 24 Teeter, Charles E.: Cardiac Failure of the Congestive Type 823 Toye. John E. : Discussion of Fractures 8 Wade, S. F. : Discussion of Duodenal Tube Drainage of the Biliary System 814 Wallhauser, H. J. F. : Discussion of Eczema in Infancy 226 Warren, C. B. : Discussion of Pedographic Impressions in School Children 930 Waters, Edward G.: pUn for Control of Special- ism Aug. Sup. 41 Plan for County Society Control of Periodic Health Examinations 956 Weber, F. C. : Bacterial Heart Failure 760 Weigel, Elmer P. : Discussion of Fractures 9-13-14 Wells. Walter A.: The Noises of Civilization and Their Evil Effects 653 Wherry, E. G. : Discussion of Eczema in Infancy 227 Wile, Ira S. : Integration of the Child 103 Williams, F. E. : Mental Hygiene 60 Wolf, I. J. : Recent Advances in Acute Poliomyelitis. . 936 Wright. Harold Edwin: Pre-School and School Physi- cal Examinations 61 Yaguda, Asher: Development cf a Postmortem Service 636 Yazujian, Dikran M.: Discussion of Tonsillectomy 30 Zehnder. Charles: Discussion of Ocular Muscle Abnor- malities . ... 926 B Board of Medical Examiners: Annual Report Aug. Sup. 29 Reported Prosecutions 63, 516 Board of Trustees, Report Aug. Sup. 20-51 Budget Committee Report Aug. Sup. 20 Business Committee: Appointment of Aug. Sup. 14 Report of Aug. Sup. 45 C Charter, Committee Report on Aug. Sup. 21 Child Health and Protection Aug. Sup. 12-48 COLLATERAL READING— How’s Your Blood Pressure? 951 Noguchi i 778 On an Anthology of Chestnuts 254 Real and Unreal 712 Review of Some Medical Books 433 Santa Claus and New Books 145 Some New Books 360 The Future of Freud — William Healy, Augusta F. Bronner, Anna Mae Bowers 52 The Immortal Lydia 664 Will Other Worlds Affect Our Health ? 870 COMMITTEE REPORTS— Board of Trustees Aug. Sup. 20, 51 Business •> Aug. Sup. 45 Charter Aug. Sup. 21 Constitution and By-Laws Aug. Sup. 3-35 Defense and Indemnity Insurance Aug. Sup. 33 Delegates to American Medical Association .. Aug. Sup. 36 Editor and Executive Secretary Aug. Sup. 6 Field Secretary Aug. Sup. 24 Finance and Budget Aug. Sup. 20 Health, Accident and Automobile Insurance. .Aug. Sup. 34 Honorary Membership Aug. Sup. 28 Hospitals and Medical Education Aug. Sup. 33 Judicial Council Aug. Sup. 17 Nominations Aug. Sup. 49 Post-Graduate Education Aug. Sup. 30 Program and Arrangements Aug. Sup. 3-19 Publication Aug. Sup. 2 Scientific Work Aug. Sup. 2 Secretary , Aug. Sup. 4-14 State Board Medical Examiners .. Aug. Sup. 29 Treasurer Aug. Sup. 19 Welfare Committee Aug. Sup. 27 COMMUNICATIONS— Abell Commission Report; Letter from Dr. Elias J. Marsh 62 Active Immunization Against Measles 447 Additional District Health Officers 596 American Association for the Study of Goiter 172 American College of Physicians 517, 879 American College of Physicians Clinical Session 171 American Physiotherapy Association; Letter from Dr. Harold D. Corbusier 63 An Interesting Item of History 675 Another Question of Ethics 675 Arc We Facing Social Control of Medical Practice?.. 674 Child Guidance — William Doody 595 Concerning Salt- Free Diet and Focal Infection 724 Councilor District Meeting; Letter from L. Cook Osmun 63 Crippled Children’s Commission 975 Defense Against Malpractice Suits 596, 725 Errors in Official List 447 First Councilor District Meeting 447 Gorgas Prize to New Jersey Girl 596 How French Dentists Met the Insurance Question 723 How Practipedists Are Made 976 Important Notice Concerning Health and Accident In- surance 976 INDEX Impressions of Annual Conference of Secretaries of Constituent State Medical Associations, 1930 — George N. J. Sommer 60 Mental Hygiene; Letter from Dr. F. E. Williams 60 New Jersey Conference of Social Work 974 One Reason Why Patent Medicine Venders Thrive.. 445 Pre-School and School Physical Examinations; Letter from Dr. Harold Edwin Wright 61 Society for the Relief of Widows and Orphans of Medi- cal Men in New Jersey; Forty-ninth Annual Report 674 Survey of Chronic Illness in New Jersey 974 Violations of Medical Practice Act 63, 516 Walt Whitman Hotel 64 CONFERENCES— Secretaries and Reporters of County Societies 956 Tristate Medical .. ,...148, 497, 585 Constitution and By-Laws Committee Report. .Aug. Sup. 3-35 Corrections 245 Errors in Official List 390, 447 Errors in The Journal 943 CURRENT EVENTS— American College of Physicians 513 American Medical Association Convention 666 Dr. R. D. Freeman Lauded at Dinner 875 Fifth Councilor District Meeting 261 New Jersey Conference on Child Health and Protection 511 New' Jersey Tuberculosis League 874 Present Status State Society — Rutgers Post-Graduate Course 259 Seventh Annual Conference of County Society Secre- taries and Reporters 956 The Physician’s Economic Contribution to the Com- munity—Charles Gordon Heyd 258 Urges Development of Posture Practice. Finds Cure for Old Age 875 Welfare Committee Minutes 64, 65, 363 Would Elevate Chiropractic 875 D Deafness— American Federation of Hard of Hearing 953 DEATHS— Beatty, Henry Moore 990 Benjamin, Dowling 84 Blair, James A 602 Blake, Duncan Williamson 286 Colhoun, Charles 390 Commorato, John 84 Craythorn, Charles J 538 Davis, Lester R 730 De Grofft, Eugene E 286 Demarest, Frederick F. C < 465 Donges, John W 390 Dowling, Charles E 898 Frazer, Thompson 898 Garrison, Biddle H 730, 794 Hedges, Benjamin Van Doren 83 Hunter, James J 601 Kitchen, J. M. W 286 Koch, Louis A ; 678 Lamson, William J 990 Lawrence, George W 465 Lindley, Charles L 538 Lockwood, Frank Wesley 730 McCormick, Daniel L 84 Madden, Walter 466 Mercer, Archibald 990 Moore, John H 186 Morse, George Vane 84 Osmun, Louis Cook 466 Paczkowski, Thaddeus . 898 Savoye, Richard G 186 Schureman. James Percy 538 Scott, George 466 Seibert, Raymond S 538 Simpsen, Maxwell S 990 Stratton, William N 538 Taggart, Thomas Dartnell 794 Van Mater, John H 730 Voorhees, Nathaniel Whitaker 602 Webster, D. King 466 Wilson, Norton L 950 Defense and Indemnity Insurance Aug. Sup. 33 DISCUSSION OF PAPERS— A Case of Pseudo-Hermaphroditism 899 A Few Thoughts in Therapy for Ailing Medical Prac- tice Neither New Nor Official 960 A Plan for County Society Control of Periodic Health Examinations 956 Cardiac Irregularities 903 Cardiac Irregularities and Silent Mitral Stenosis 912 Changes in Human Rickets After Viosterol Therapy.. 21 Clinical Evaluation of a Concentrate of Vitamins A and D 853 Clinical Management of Heterophoria 919 Combined Orthoptic and Operative Treatment of Con- vergent Squint in Young Children 923 Diet in Eczema of Infants 222 Eczema in Infancy 226 Essentials in Infant Feeding 216 Forcible Extension in an Ankylosed Joint 914 Fractures 8 Fusospirochetal Disease of the Lung 849 Gastro-Intestinal Disorders 20 Integration of the Child 109 Is Group Medical Publicity Ethical? 1. 961 Local County Medical Society Publicity 962 Malnutrition in Children 211 Non- Pathologic or Functional Heart Murmurs in Chil- dren 102 Ocular Muscle Abnormalities 926 Overlapping the Rectus Muscles for Correction of Stra- bismus 915 Pedographic Impresions in School Children 930 Some Oddities in Acute Mastoid Disease 26 Symposium on Public Health Work 206 Surgical Aspects of Biliary Tract Disease 797 The Physician’s Part in the Training of Teachers 935 Tonsillectomy 30 Treatment of Whooping Cough 99 Value of Duodenal Tube Drainage of the Biliary Sys- tem in the Treatment of Various Diseases of the Liver 813 E ECONOMICS— Are We Underpaid? — H. M. Tolleson 578 Family Doctor’s Income in Relation to Preventive Medicine 578 The Open Hospital — William H. Ross 51 Editor: Presessional Report of 439 Regular Annual Report of Aug. Sup. 6 EDITORIALS— Adding Insult to Injury 133 Advance Notice of Annual Meeting 425 An Apt Phrasing of Medical Ethics 781 Asbury Park Convention 579 Automobiles More Deadly Than War 861 Control of Specialism 243 County Society Advertising 131 County Society and Hospital Reports 426 Crippled Children’s Commission 779 Doctors Are “Easy Marks’’! 351 Entering Upon a New Fiscal Year 580 Errors in the Journal 943 Fractures and the Compensation Law 49 Growing Importance of Mental Hygiene 780 In This Issue 245 Interesting Information Concerning Old Golds 493 Iowa Plan of Securing Payment for Services to the Community's Indigent Sick 49 Legislation in the Making 245 Medical Service of the Future 132 Necessity for Vacations 661 Negotiating Loans for Medical Expenses 244 New Year Greetings — George N. J. Sommer 49 Newspaper Publicity j 713 Parlous Times 941 Personal Interest and Activity 353 Preliminary Announcement Regarding Post-Graduate Medical Courses 863 Revision of Public Health Laws 714 State Medicine 352 Status of State Medicine 426 Study of State Medicine 662 The Official Transactions 661 The Passing Westward of Osmun and Lawrence 425 The Physician an Idealist 352 What Price Football! 942 Workman’s Compensation Law 713, 863 Election of Officers Aug. Sup. 49 ESTHETICS— Appreciation of Good Music 254 Consider the Dreamer 360 Culture — Thomas G. Orr 581 Make Your Own Murals 494 Music in Relation to Art and Life 54 Musical Matters of Interest to Physicians 868 Phlebitis — E. S. Corson 142 Recognition of Home Talent 141 INDEX Requiem to the Unknown Soldier — Ralph S. Cone 142 Roadside Esthetics ~8J The War Nurse’s Story — Ralph S. Cone 141 The Windmill Orchestra Conductor , .... 717 ETHICS— C’est Formidable L'Opiniou Publique 717 Character — Decent Conduct 782 Hurry, Hurry, Hurry! -. 952 Lowering of the Standard of Ethics 53 Medical Societies 581 More Health Ethics 143 Patients Must Not Be Neglected 432 Success 867 The Law Is an Ass .t., 663 The Physicians in Holy Writ 252 Times Square Has a Summer Visitor 663 Uphold Honor of the Profession 494 “Who Steals My Purse Steals Trash" 359 Executive Secretary: Presessional Report of 439 Regular Annual Report of Aug. Sup. 6 Reports to the Welfare Committee 64, 65, 363 F Field Secretary, Report of Aug. Sup. 24 G Group Defense and Indenmnity Insurance Aug. Sup 33 Group Health and Accident and Automobile Insur- ance Aug. Sup. 34 H Hard of Hearing, American Federation of 953 House of Delegates, Transactions of Aug. Sup. 1-56 I INSURANCE— Defense and Indemnity Aug. Sup. 33 Health and Accident and Automobile — ..438, Aug. Sup 34 Important Notice Concerning Health and Accident In- surance 976 J Judicial Councilors, Reports of Aug. Sup. 17 L Lighthouse Observations 55, 147, 148, 257, 441, 497, 583, 665, 666, 719, 720, 784, 872, 953 M Maternal Welfare, Resolutions on . ,..Aug. Sup. 42 Medical Defense and Indemnity Insurance ...... Aug. Sup. 33 Medical Examiners, Report of Prosecutions Aug. Sup. 9, 63, 516 Membership. Official List April Sup. 1-48 Mental Hygiene, Committee Report ....Aug. Sup. 48 N New Jersey Conference on Child Health and Protection 511 Nominating Committee Report Aug. Sup. 49 O OBSERVATIONS FROM THE LIGHTHOUSE— Acute Hemorrhage from Corpus Luteum and Graafian Follicle 665 American Federation of Organizations for the Hard of Hearing 953 Combination Anesthesia 583 Diagnostic Relationship of Physician and Dentist...... 872 Head Injuries 441 Management of Angina Pectoris 597 Massage in Rehabilitation Work 148 Mental Hygiene and Industry . 720 Mental Hygiene and the Child 666 Practical Use of Spinal Anesthesia 719 Public Relations Committee 55 Rehabilitation of the Disabled 147 The Patient with Heart Disease 257 Vocal Cords of Metal 257 Why We Reach for That Sweet 784 Officers, Election of Aug. Sup. 49 Official Transactions, Annual Meeting ........ Aug. Sup. 1-86 ORIGINAL ARTICLES— Acute Abdomen — John B. Deaver 407 Acute Perforation of Peptic Ulcers — Royal A. Schaff.. 417 A Doctor's Confession of Faith — Wells P. Eagleton 2S7 Advantages of General Anesthesia in Tonsillectomy — William Campbell 29 A Group of Endocrine Cases — Frank J. T. Aitken 470 Alcoholic Pseudo- Pellagra — N. B. Heller 467 Anemia of Pregnancy — Robert A. Kilduffe 341 An Historical Sketch of Development of Preventive Medicine in New Jersey— J. Bennett Morrison 731 Are We Underpaid? — H. M. Tolleson 578 A Romance of Paternalism — Walter F. Donaldson 587 A Skin Test for Whooping Cough — Charles V. Craster, Ellis Smith 236 Asthma from the Standpoint of the Rhinologist — Lyn- don A. Peer 692 Automobiles More Deadly Than War — Henry O. Reik 148 Bacterial Heart Failure — F. C. Weber 760 Bacteriologic Study of Chronic Infectious Arthritis — John W. Gray, Cecil H. Gowen 38 Cardiac Failure of the Congestive Type — Charles E. Teeter ■ 823 Changes in Human Rickets After Viosterol Therapy — John Caffey 21 Child Guidance— William Doody 595 Child Hygiene — Julius Levy 694 Circulatory Disturbances in the Extremities of Dia- betics— David W. Kramer 560 Clinical Evaluation of a Concentrate of Vitamins A and D — Joseph H. Marcus 850 Clinical Significance of High and Low Blood Pressure — R. Burton Opitz 302 Common Conditions in Industrial Ophthalmology — George J. Dublin 7C4 Common Diseases of the Oral Mucosa — Bart M. James 563 Consideration of the Causes of Diarrhea — E. W. Rod- man 548 Constipation — Hilton S. Read 755 Continued Education of the Doctor — John A. Hartwell. 639 Councilor District Meetings — Dr. Snedecor 506 County Society — S. Emlen Stokes 114 Cult of Askiepios — Walter B. Stewart 603 Culture — Thomas G. Orr 581 Danger Ahead in the Cathartic Habit — Hilton S. Read 660 Development of a Postmortem Service— Asher Yaguda 636 Development of Public Welfare Work — William J. Ellis 187 Diabetes Mcllitus and Thrombo angiitis Obliteians in the Same Patient — Harold S. Davidson 570 Diet in Eczema of Infants — F. I. Krauss 217 Differential Diagnosis of Lead Poisoning — Joseph S. Mark 334 Doctor and the Law — Robert Peacock 203 Duodenal Stasis — Charles Frederick Baker 1 Dust and Bacterial Factors in Asthma — Royce Paddock 687 Eczema in Infancy — F. J. McCauley 223 Essentials in Infant Feeding — Percival Nicholson 212 Etiology, Diagnosis and Treatment of Peptic Ulcer — George H. Lathrope 344 Factors in the Early Diagnosis and Treatment of Frac- tured Skulls — H. Wesley Jack 608 Female Sex Hormone — Rita S. Finkler 766 Foreign Body in the Urinary Bladder — R. L. McKier- nan, H. H. Goldstein 709 Fungus Infection of the Skin — S. J. Fanburg 92 Fusospirochetal Disease of the Lung — F- J- Altschul, C. A. Pons, W. G. Herrman 834 Gastro-Intestinal Disorders — Charles Gilmore Kerley.. 14 Gastro-Intestinal Patient — Joseph M. Marcus 90 Generla Practitioner and Obstetrics — Samuel A. Cos- grove 545 Health Department Growth in New Jersey — D. C. Bowen 196 Hereditary Epistaxis — Hyman I. Goldstein 309 High Lights in the Life of Robert Koch — Harry Subin 342 Indications for Surgery in Diseases of the Thyroid- William Barclay Parsons 481 Influence of Public Health Activities on Medical Prac- tice— Julius Levy 193 Integration of the Child — Ira S. Wile 103 Intradural Caudal Anesthesia — G. T. Spencer 235 Leukorrhea- P. Brooke Bland 489 Liver Cysts— John II. Hermann, Guy B. Griffin 337 Looking at the F'acts in the High Cost of Medical Care — Erwin Reissman 854 Malnutrition in Children— L. Charles Rosenberg 208 Medical Ethics — Harry H. Bowles 35 Medical Possibilities of Sea Water — C. L. DeMeritt... 706 Medical Service of the Future — G. W. Haigh 115 Medicolegal Aspects of Disability in Industrial Lead Poisoning — Max Kumme! 327 Memorial Tablet to Dr. O. H. Sproul — John F. Hagerty 110 Modern Treatment of Varicose Veins — V. Earl Johnson 229 Moses Maimonides — Physician and Philosopher — S. Schiffmann 750 Myocardosis; The Failing Heart of Middle Life — Aaron E. Parsonnet, Albert S. Hyman 831 New Method of Outlining the Heart, Its Chambers and Great Vessels — Clyde M. Fish 817 Noises of Civilization and Their Evil Effects — Walter A. Wells 653 Non -Pathologic or Functional Heart Murmurs in Chil- dren— Irving Okin 100 Obligations of Professional Medical Service — William H. Ross 159 INDEX Obstetric Mortality — J. C. Hartman 31 Observations in the Vienna Eye Clinics— A. Russell Sherman 485 Occupational Dermatitis — John E. Kiley 613 One Year of Neurologic Service — Karl Rothschild 478 Our Responsibility for Public Education Regarding Comparative Costs of Sickness— Ross V. Patterson.. 585 Pedographic Impressions in School Children — Donald B. Hull 928 Physicians’ Economic Contribution to the Commun- ity— Charles Gordon Heyd 258 Physician's Part in the Training of Teachers — Grace M. Kahrs 932 Plastic Surgery— Tacques W. Maliniak 679 Practical Gastro-Enterology — J. Gerendasy 768 Practical Management of Diabetes— James Ralph Scott 304 Practitioner’s View of Medical Economics — F. I. Krauss 743 Presidential Address — George N. J. Sommer 539 Prevention and Control of Lead Poisoning in Industry— Joseph S. Mark 773 Preventing the Transmission of Syphilis— John H. Stokes 39J Prevention of Measles — George Heller 617 Public Relations as a Specific — John S. Irvin 959 Publicity, A Remedy for Many Society Froblems— R. I. Downs 959 Radiographic Diagnosis of Gall-Biadder Pathology— Louis J. Gelber 829 Recent Advances in Acute Poliomyelitis — I. J. Wolf. . 936 Recurring Postoperative Parotitis— Harold S.‘ Davidson 85 Refraction and Health — Pierce Shope ,. 697 Relation of Arteriosclerosis to Cardiac Pathology— Jacob Polevski 753 Relation of Traumatic Surgery to Industry— J. W. Martin ‘ g Report of Governor Roosevelt’s Commission to De- vise a Public Health Program— William H. Ross 508 Review of Recent Literature on Thrombo-angiitis Ob- literans— Max Gross 57] Rupture of Gastric Ulcer— Edward C. Klein, jr. 412 Short History of Diphtheria Eradication— BeHhold T. D. Schwarz 539 Significance and Diagnosis of Silent Mitral Stenosis— J. Polevski 910 Sinusitis — E. S. Hallinger 475 Some Difficulties of the Asthma Problem— George H7 Lathrope ^84 Some Oddities in Acute Mastoid Disease— W. L. Pan- nell 22 Sciir,e s . Information and Misinformation in Cardiac Diagnosis — Jacob Polevski 121 Some Thoughts on Medical Economics and Medical Practice — S. Rubinow 218 Squint in Childhood and Its Effect in Later Life— Wii- lard G. Mengel 700 State Department of Labor in Relation to the Public and Medical Profession — Henry H. Kessler 200 Statistical Study of Diphtheria in Newark— Joseph William Gardam ‘ g3g Surgical Aspects of Biliary Tract Disease-^- John B Deav« 795 Thrombosis and Embolism — Frederic W. Bancroft 619 Tonsillectomy bv Diathermy— A. S. V. Giglio 771 Tonsillectomy Under Local Anesthesia— Robert H Fowler 27 Treatment of Active Measles by Intramuscular Injec- tion of Recent Convalescent Whole Blood— Jacob Filler 340 Treatment of Acute Coronary Thrombosis— Albert S. Hyman, Aaron E. Parsonnet 396 Treatment of Bight’s Disease— Rolfo Floyd 55? Treatment of Perforated Peptic Ulcer— Herbert A. Schulte 40J Treatment of_ Whooping Cough— A.' ' S.' ’ Fi’n’keistein .' 96 Tube Flaps in Reconstructive Surgery of the Face— Lyndon A. Peer gg Useful Irrigating Fluid for Septic Wounds— H. h! Gold- 492 819 Uterine Hemorrhage Radiologically Considered— W. G Iierrman Value of Blood Sedimentation Test in Gynecology John Huberman 403 Value of Duodenal Tube Drainage of the Biliary Sys- tem in the Treatment of Diseases and Disorders of the Liver — B. B. Vincent Lyon 799 What Are State Departments of Labor Doing to Ad- vance Industrial Surgery ?— Round Table Discussion. 498 What Is Wrong with the Fracture Situation ?— J. K. Adams j What the Present Day Public Thinks’ ' of' 'the ' Medical PERSONAL ITEMS— POEMS— De Profundis 242 Don’t Quit ; 777 Phlebitis — E. S. Corson 142 Requiem to the Unknown Soldier— Ralph S. Cone ..... 142 September 712 The Bell Buoy — Ralph S. Cone 577 The Love of Books 859 The War Nurse’s Story — Ralph S. Cone 1 141 Today 41 POST-GRADUATE EDUCATION— Preliminary Announcement Regarding Post-Graduate Medical Courses 863 Committee Report • Aug. Sup. 30 Preliminary Program of. Annual Meeting 435-441 Pre-School Child, Medical Care of . ...Aug. Sup, 50 President: Annual Address of 539 Opening Address to House of Delegates Aug. Sup. 1 PRESESSIONAL REPORTS— Committee on Health and Accident and Automobile Insurance 438 Editor and Executive Secretary 439 Treasurer 496 Welfare Committee , 438 PROGRAM AND ARRANGEMENTS— Annual Report : ..-. .Aug. Sup. 3-19 Preliminary Report 435-441 PUBLIC RELATIONS— Agree Not to Publish Doubtful Advertising . 876 Announcement of the First Award Under the Thomas W. Salmon Memorial 263 A “White Collar” Hospital That Is Proving the Case 514 Bill No. 304 Abell’s 57 Consultation Service at Mt. Sinai Hospital for People of Moderate Means 721 Control of Proprietary Medicine 514 : Copyright Glasses ;..... 972 Disclosure of Diseases Under Prohibition Act Abolished 261 Doctor’s Dilemma 878 Future of Surgery 723 Generosity Runs Riot 722 Governor Looks at Chiropractic 442 Hold Free Foot Clinic in Resort This Week 878 How Science Nipped an Epidemic 169 “In a Heluva Fix” .-... 972 Infant Mortality Lowest in History 57 Leadership in Medicine 878 Legal Voluntary Euthanasia 972 Male Prostitute Convicted 720 Measurement of Noise 784 Medical Cowards 722 More Persons in Mental Than in General Hospitals.. 671 New Jersey Pharmaceutical Convention 671 Newark Tops Class in Health Rating 442 Noisy Ambulances 970 Report to the Commissioner , of Labor by the Work- man’s Compensation Advisory Commission .... 442 Smith Urges Clinics or Health Insurance , 877 Staging a Health Drive Among Pre-School Children.. 672 State Medicine and Control of Specialism 168 Surgeons Reduce Fees 57 The Hoe, a Cure for Crime 971 The New England Medical Center 262 The Supertrained Nurse 672 Tobacco 875 Vaccination Favored to Prevent -Diphtheria 877 Warning to Physicians 261 White House Conference on Child Health and Protec- tion 58 PUBLICATION COMMITTEE— Annual Report of Aug. Sup. 2 R RESOLUTIONS— Committee to Study Status iof State Medicine .Aug. Sup. 47 False and Misleading Advertisements Aug. Sup. 47 Maternal Welfare Aug. Sup. 42 Medical Care of Pre-School Child Aug. Sup. 50 Medical Care of School Children Aug. Sup. 43 Mental Hygiene Aug. Sup. 48 Motor Vehicle Accidents Aug. Sup. 48 Prohibition ; Aug. Sup. 5 Specialists and Specialism Aug. Sup. 37 Jan., xxiii. ; Feb., xxviii.; Mar., xxi.; Apr., xxi.; May, XXI.; June xxi.; July, xxi.; Aug., xxi.; Sept., xiv.; Oct., xiv.; Nov. xiv. S SCHOOL CHILDREN— Medical Care of Aug. Sup. 43 INDEX SCHOOL HEALTH DEPARTMENT— Cafeteria and Luncheon 785 Clippings 723 Minimum Bibliography for School' Physicians 515 Notes from Los Angeles 444 Notes of General Interest 365 Physician’s Part in Hygiene and Sanitation of the School Building 879 Pupil Supervision 673 School Physician’s Part in Health Education 973 Special Meeting of School Physicians 263 Standards for Prevention and Control of Contagious Diseases 169 Suggested List of Activities for School Physicians 597 School Health Work — Request of Dr. Ireland. .Aug. Sup. 35 School Physicians, Section of ! Aug. Sup. 62 Scientific Work, Report of Committee Aug. Sup. 2 Secretary: Annual Report Aug. Sup. 4-14 Secretaries and Reporters of County Societies. Annual Conference 956 SOCIETY REPORTS— Councilor District Meetings: Councilor District Meeting 63 First Councilor District Meeting 276 Second Councilor District 522 Third Councilor District 894 Fifth Councilor District 450 Round Table Discussion of 506 County Medical Societies: Atlantic 71, 175, 268, 370, 450, 519. 883, 978 Bergen 73, 178, 271, 375, 450, 522, 791, 885, 979 Burlington 271, 376, 523 , 782, 980 Camden 73, 178 , 272, 377 , 451, 524, 886, 982 Cape May 982 Cumberland 179, 451, 678, 886 Essex 73, 179, 272, 377, 451, 524, 886, 982 Gloucester 74, 179. 277 , 382 , 454 , 526, 793 . 888 , 983 Hudson 74. 180. 277, 382, 454, 526, 888 Hunterdon 184. 462, 987 Mercer 81, 184, 284 , 388, 462. 534 , 599. 893 , 988 Middlesex- 81, 184, 388, 463, 599, 895, 988 Monmouth 82, 285, 389, 463, 535, 599, 896 Morris :82, 185 , 389. 536, 600, 793 , 988 Ocean 163, 537, 988 Passaic 83, 185 , 285 , 390. 463 , 537 , 794, 896, 989 Salem 285, 464, 897 Somerset 285, 464, 600, 897 Sussex 286, 989 Union 185,464,678,897 Warren ...186, 537, 989 Local Societies: Academy of Medicine of Northern New Tersey 381, 526, 888, 983 Eye, Ear. Nose and Throat Section 74, 179, 272, 379, 453, 525, 888, 983 Atlantic City Hospital Staff 71, 176, 268, 374, 520. 598, 677, 728, 788, 885, 979 Bayonne Hospital Clinical Conference. . 180, 283 , 461, 890, 987 Jersey City Medical Center 80, 460 North Hudson Hospital Clinical Society 77, 182, 383, 458, 531, 891, 984 Pine Rest Sanatorium 72 Rutgers Medical Club 82, 185, 388, 535, 599, 895 Summit Medical Society 185, 464, 537, 897 Westfield Medical Society 83, 898, 989 SPECIAL ARTICLES— Medical Travel Talk — Henry O. Reik...42, 135, 246, 354, 427 Recent Visit to the Grenfell Mission on the Labrador- Travel. Visit to Royal Victoria Hospital, Montreal— John Hammond Bradshaw 715 John Hammond Bradshaw 864 Some Observations Upon Health Matters in England— Henry O. Reik 944 SPECIALISTS AND SPECIAL1SM- Plan for Control of Aug. Sup. 41 Resolutions on Aug. Sup. 37 STATE HEALTH DEPARTMENT— District Health Officers 597 Laboratory Tests in Undulant Fever 366 Narcotic Control 516 Pasteurization of Milk 170 Spotted Fever 673 State Health Laws 59 State Medicine, Committee to Study Aug. Sup. 47 T Transactions, Annual Meeting Aug. Sup. 1-86 Travel Article: A Visit to the Royal Victoria Hospital, Montreal 715 Treasurer, Annual Report Aug. Sup. 19 Presessional Report 496 Tristate Medical Conferences 148, 497, 585 Trustees: Annual Report Aug. Sup. 20-51 W WELFARE COMMITTEE— Annual Report Aug. Sup. 27 Minutes of November Meeting 64 Minutes of December Meeting 65 Minutes of March Meeting 363 Presessional Report of 438 WOMAN’S AUXILIARY— Adulteration of Foods 879 Annual Meeting, Minutes of Aug. Sup. 63-86 Annual Meeting, Transactions of Aug. Sup. 63-86 A Task Proposed for the Auxiliary 726 Attention Ladies 172 Executive Board Meeting 448, 881, 976 Note from the Editor 367 Panoramic View of the Woman’s Auxiliary to the American Medical Association 172, 367, 598, 676 Preliminary Program Woman’s Auxiliary to the Ameri- can Medical Association 173 Society for Relief of Widows and Orphans of Medical Men of New Jersey — Edward J. Ill 69 State Society Auxiliary 70, 173 Winning Them Over 70 Woman’s Auxiliary A. M. A. Ninth Annual Conven- tion 517 Woman’s Auxiliary to the American Medical Asso- ciation 786, 977 Woman’s Part in Medical History. Jane Todd Craw- ford— The Model Patient 264 Women at the A. M. A. Philadelphia June Meeting.. 448 County Reports: Atlantic 174, 266, 369, 518 Bergen 70, 369 Burlington 881 Camden 174 Essex 174, 266, 369, 881, 977 Gloucester 70, 266, 369 , 449, 519, 881, 977 Hudson 70, 267, 370, 449, 787, 882, 978 Hunterdon 449, 978 Mercer 267, 519, 978 Ocean 267, 882 Passaic 174 Somerset 175, 370, 882 Union 175, 267, 370, 449, 727, 882 Workman’s Compensation and Contract Practice, Com- mittee on Aug. Sup. 45 Journal of The M edical Society of New J ersey Published on die First Day of Every Month Under the Direction of the Committee on Publication Vol. XXVIII., No. 1 ORANGE, N. J„ JANUARY, 1930 Y“r DUODENAL STASIS* Charles Frederick Baker, M.D., Newark, N. J. Duodenal stasis is undoubtedly much more frequent than was formerly recognized. That it may be the cause of symptoms which we have been prone to lay to diseases of the ap- pendix and gall-bladder is a possibility with which we must reckon, for operations upon those organs do give relief, unless coincidently the factors producing duodenal stasis are rec- ognized and, so far as possible, corrected. The causes of duodenal stasis may produce continuous or intermittent effects. Those producing continuous mechanical obstruction and interference with normal duodenal mo- tility may be extrinsic or intrinsic. The ex- trinsic are peritoneal bands resulting from cholecystitis ; anomalies of the pancreas in- cluding tumors or annular pancreas ; compres- sion by the superior mesenteric or other ar- teries in the mesenteric root, behind which lies the horizontal portion of the duodenum ; gas- troptosis and ptosis of the colon and small in- testine. The intrinsic causes include anom- alies of duodenum, size and position; ulcer; tumors ; etc. Those producing intermittent or temporary stenosis are attributed by some to neuromuscular derangement ; by others to su- perior mesenteric artery compression accom- panying right-sided ptosis or ptosis of the small intestine. Conceivably, a drag upon the ♦(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Atlantic City, June 13, 1930.) mesentery, producing intermittent stasis, may follow periods of atonicity during severe physical and nervous depression, particularly with overloading of a low cecum and conse- quent increased dragging upon its support ; whereas, when, following rest or general re- laxation a better tone develops, an improve- ment would occur. Ptosis of the stomach, by a dragging down- ward of the upper portion of the duodenum, causes an unusual angulation of the upper- third of the descending portion, with stenosis and dilatation. Inflammatory bands, result- ing from cholecystitis and periduodenitis fol- lowing ulcer, as well as anomalous develop- ment of the peritoneum or failure of absorp- tion of embryonal peritoneum, affect the lower angle or junction of descending and horizontal portions. Pressure by the superior mesenteric or other branches which leave it or the aorta at about the same level, gener- ally produce dilatation and stenosis in the horizontal portion. Inflammatory bands be- tween the duodenum and jejunum at the duo- denojejunal angle are generally the causative factor in stenosis of the ascending portion. The superior mesenteric artery leaves the aorta above the horizontal portion of the duo- denum, which it crosses, and gives off the midcolic, right colic, ileocolic and terminal branches to the small intestine. Many anom- alies occur in this as in other anatomic structures. As stated by Kellogg: “The arterial walls possess little elasticity as compared to the tis- sues which surround them and when the or- gans to which the arteries are distributed be- 2 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 come prolapsed, the latter become their chief support and may compress the duodenum. For this reason, prolapse of the small intes- tine compresses the third duodenal segment, by a direct pull upon the superior mesenteric artery, providing the prolapse is not sufficient to permit the intestines to rest upon the pelvic floor. Prolapse of the cecum drags upon the ileocolic, and through it on the superior mes- enteric, causing compression at the same point. With descent of the hepatic flexure, the right colic, when it crosses the duodenum, compresses the second or third segments proximal to the mesenteric root. More than one artery may be involved and (this is im- portant) a combination of arterial compres- sion and congenital or acquired bands is com- mon.” Symptomatology. The symptoms are due to the mechanism of obstruction and to the tox- emia, which is severe in direct proportion to its proximity to the pylorus. From the ob- struction we find nausea or vomiting. The latter may be either spontaneous or forced, to obtain relief, and occurring or produced after a relatively short period following reception of food into the stomach; pain in the upper abdomen, either to the right or left of the median line, and often deep and referred to the back as in cholecystic disease; it may also radiate to the shoulders. The pain may be very severe or there may be complete absence of this symptom. It may be relieved by pos- ture, particularly if a change of position re- lieves a drag of the prolapsed intestine. These symptoms may be worse when the cecum is over-full and constipation is present. If the compression affects the region of the ampulla of Vater, secondary effects may be present in the liver, with enlargement and increased sensitivity of both liver and gall-bladder. I he toxic effects are more or less of a mi- graine character: so-called bilious attacks which may have originated in childhood, ushered in by marked constipation and head- aches ; disturbance of mental processes ; severe physical depression ; disturbed heart action ; poor peripheral circulation ; hyper and paresthesias ; skin eruptions ; subnormal tem- peratures and blood pressure, most of which arc typical of toxemias in general. Physical examination may reveal unusual tenderness along the course of the duodenum, ;f it is distended, and a tympanitic note may be found behind the right rectus muscle to the right of and below the pylorus between the liver and transverse colon. Duodenal succes- sion may be elicited. Pressure may sometimes empty the duodenum and the gas may be heard as it rushes into the jejunum; follow- ing which the area of tympany disappears. The Roentgen-ray examination may easily settle the diagnosis but when the cause lies chief!} in mesenteric compression a negative report is common. The reason for this is that the mechanism may not always operate to produce partial obstruction, with delay in the passage of the barium content through the duodenum, and peristalsis may at the time of the examination be excellent. Improved peri- stalsis may result from a rest period of a few days or weeks preceding the x-ray ex- amination ; or a cathartic the day before may so improve peristalsis that stasis is overcome. 1 he radiograph may reveal varying degrees of stasis from simple lagging in the flow of the intestinal contents to complete stoppage. The normal current through this organ is so rapid that a true intestinal outline of the duo- denum is never seen, unless delay exists. The barium shadows appear as mere flecks dis- seminated along its course. As the barium mixture distends the dilated duodenum, valvulae conniventes appear, which under or- dinary circumstances are generally first recog- nized in the upper jejunum. Hence, any films showing a distinct intestinal outline, in the regions of the descending or horizontal portions, should at once intrigue us into care- ful analysis of Roentgen and physical find- ings and symptomatology, to see if we can- not unravel the mysterious cause of a chronic dyspepsia which may have bothered the pa- tient for a considerable time and for which he may have already been operated upon with- out relief. In cases showing greater dilation in the more obstructive lesions, the signs are so ap- parent that literally one who runs may read Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 3 the findings. The duodenum may be 2 or 3 times its normal diameter, and the stomach also dilated. Under the fluoroscope, the duo- denum may be seen to writhe in spasm, and waves of reverse peristalsis may be demon- strated. It is held by some that fluoroscopy is the method of choice in detection of this con- dition. If it is not used many pictures should be made with the patient in different postures, at least the prone, oblique, lateral and vertical. Treatment. Many cases are amenable to the usual measures employed to relieve en- teroptosis and intestinal stasis. Surgical measures are indicated when medical fail to relieve. Some are plainly surgical in the be- ginning, notably those in which the duodenum is greatly dilated or is causing frequent cop- ious regurgitation of bile. Personally, I do not feel that it is pertinent for the roentgen- ologist to discuss the various surgical meas- ures and will leave that to others. WHAT IS WRONG WITH THE FRACTURE SITUATION* J. K. Adams, M.D.. East Orange, N. J. Some well meaning persons suggested that I read a paper on fractures in 15 minutes. This seemed to me a good deal of a contract, and I wrote the Secretary that 1 really did not think I could do that, but that instead I might make a few remarks on the fracture situation in general, which perhaps might promote a discussion. At any rate, I will promise you one of the shortest papers that was ever read before this society, if you want to call it a paper. It seems to me that there is something wrong with the fracture situation, and that the great- est trouble lies in the present arrangement of services in our hospitals. I am assuming that it is the earnest desire of each and every one of us who treat these conditions to have the hospital services so arranged that the patients *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Atlantic City, June 14, 1930.) will get the greatest benefit possible. It seems to me that “rotating” services, where from 2 to 4 different men handle a case, do not give the best results. The responsibility is divided. The problems facing each man as he goes on duty are not as clear cut and well defined as they would be had he handled the case from the beginning. This creates a situation that is distressing to the patient and his relatives, not to mention some of the doctors. A frac- ture occurring the latter part of the month is often delayed in receiving the attention it should, in order that the man coming on duty the first of the next month can handle it from the beginning; and patients who should have their casts or apparatus removed near the end of a month are often left over to the first of the next month for the man who originally put the cast on to take over the case again. It occurs to me that there is nothing stimulating about such a service. It lacks interest and, frequently, the functional results suffer. The medical profession created this type of ser- vice ; we created it, and it is up to us to get rid of it. No one else is responsible. It seems time for a change, and it has been changed in many hospitals with very gratifying results. As I see the problem, there are 3 things that can be done : (1) Have a service called a “Fracture Service”, to be under the charge of one man with as many assistants as the work requires. The entire responsibility will be his and all due credit will be his. He cannot pass the buck to anyone. The compensation income from such cases might be divided between the Fracture Service Staff and hospital; that is, if they want to divide it. What you do with the money so derived does not matter much because it amounts to an extremely small sum to any one person. It could very well be spent on equipment, which is not very ex- pensive. The head of such service should spend at least 2 weeks each year in visiting first class bone clinics, actively studying the manner in which they are treating these cases, and should upon returning read a written report to the staff of his hospital. (2) If the first method is not cared for, I 4 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 siiggcst the following : Let everyone treat the fractures in the old way, but at the end of the month, when a man goes off duty on everything else, let him continue to treat the fracture patients that he has been treating, and to treat them continuously until they are discharged. This method has the advantage of No. 1 in placing responsibility where it belongs, and it also prevents buck-passing. Further, it prevents men saying their fractures were taken from them. (3) A “Traumatic Surgery Service” ab- solutely continuous like No. 1 might be es- tablished. This would prevent any quibbling in a case where there is a minor fracture but decided nerve, ligament or muscle injury. There could be no misunderstanding as to whose service the case belonged, and who was to control treatment. It may interest you to know that when the new Physicians’ and Surgeons’ Hospital was started in New York it was decided to have a fracture ser- vice, but that anyone of the staff who wished could, by saying so, treat his proportion of fractures, but he was required to finish every case he started. I am told by the head of the service that since that rule was made only 1 man has asked to treat such a case, and he only asked once. Is there anyone here who does not believe that a properly organized fracture service by men interested in the subject, and who are con- tinuously working on it, will produce better results than the old rotating type where everyone tries to do everything? The fracture equipment in many of our hospitals is insufficient or poorly kept. This chaotic state of affairs is often due to the fact that the equipment is not under somebody’s special supervision. There may be a closet into which all fracture equipment is thrown; a few old Thomas’ splints, some rope and per- haps a few splints bought from some clever salesman by the superintendent but which no one would ever use. Such an assortment and a few very poor Balkan frames may con- stitute the entire equipment. The reason for this is that no one was really interested in the subject. A physiotherapy department does not ex- ist in some hospitals; massage and such trifles are not used, and there is no gymnasium with simple apparatus for restoring function. Much of the required apparatus is very in- expensive and could be made by a hospital carpenter. The following recommendations, then, oc- cur to me: First, put the fracture service on a sound basis, like the operating room. Make some one absolutely responsible for its proper functioning. Second, put in charge of the equipment some one who will keep it under lock and key, in a place where the apparatus can be properly arranged and where it can be found when needed. There is an extraordinary impression all over this country, and I guess wherever peo- ple have fractures, that the one thing to be accomplished is to get the two ends of a broken bone to grow together. That is not the most important point in treating frac- tures. I will admit that getting union is a very important detail in treatment of a frac- ture, there is no question about that, but the patient did not come to you because he had a broken leg — that is not why he came — he came to you because he had pain and loss of the use of his leg. Now, when you' have a man with, we will say, a very simple fracture of the tibia, and you have put it in a cast after it has been nicely aligned, and he is lying in bed, you are not treating him, he is treating himself. His fragments are in perfect align- ment. he gets nice union, radiograph shows that there is an excellent formation of callus ; then you are going to begin to treat him, if you do the right thing. You are ready to go ahead and treat him after he has been lying in bed for 3, 4 or 5 weeks. But in most cases this does not happen. He is discharged after the cast has been removed, and no further treatment is given him. The follow-up service in most hospitals is imper- fect. There are a few hospitals of the better class that have a good follow-up service and know what these patients are doing. From one hospital that boasts of its follow-up ser- vice I have treated 6 fracture patients who came out within the last 6 weeks, and none of them ever saw the follow-up attendant. Jan , 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 5 Put the fracture service on a sound basis, gentlemen, like the operating room. Why have you a decent operating room in your hospitals? The Board of Governors did not come to you, nor the Board of Trustees, nor the Executive Committee and say, “we insist on your having the most magnificent equip- ment that we can force upon you”. They did not say that ! Oh, no, they did not ! You went to them and said, “We can’t do the kind of work that has to be done in the hospital unless we have something to do it with”. There are no records in your staff minutes in 99% of the hospitals in this country, showing that you have ever intimated to the Board of Trustees that you wanted anything special with which to treat fractures. Go back and read over the books and see when you requested them to furnish you with apparatus that you really -could do something with. It is not there. Now, equipment is a very broad word as applied to treatment of fractures. What do I mean by equipment? I don’t mean that your hospital should be supplied with a perfectly stupendous collection of complicated me- chanical splints, the last word in the brace- maker’s art. That is not what I mean at all. If you have any such collection as that, it is -an admission by your staff that they don’t know how to treat fractures, and that they are going to use the brains of the brace- maker instead of using their own. The best fracture men that I know have no such ap- paratus. The other day a bracemaker came into my office with such a perfectly mag- nificent splint, I mean it was such a perfectly magnificent piece of mechanical excellence for the forearm and wrist, including every joint of the entire hand, wrist and elbow, that it was a mechanical masterpiece. It cost, I think, $35 or something like that. It was such a splendid and perfect piece of mechanism that, although I have no use for such a thing at all, I almost bought it just to study its mechanics. However, the great trouble with all that kind of thing is that you are fitting the patient to a mechanical appliance. That is not what you want to do. It is the greatest mistake under the sun to do this. When a fellow practices medicine way out in the coun- try and has no drug-store convenient, he has to keep some medicines on hand, and it is highly proper that he should; but for a man in a big city, that has a large drug-store near the office, it is another thing, It is foolish, when a patient comes to his office, for him to go to his closet saying, “Why, yes, I have just the thing for you”. There is no splint, I don’t care how expensive it is, how perfectly mag- nificent from a mechanical standpoint, that cannot be improved upon by a very few dol- lars worth of plaster of Paris, a little wire and a pruning knife. You can put it in any desired position and make it fit. What I mean, when I say equipment, is : You do want some Balkan frames, whether metal or wood is up to you ; the wooden frames have one very decided objection — they are a perfect nest for vermin. After you have used one for a very long time, destroy it. Make them out of cheap stuff. The vast majority of them don’t have to be very heavily con- structed. You don’t need a Balkan frame made of 2x2 lumber if you are going to treat a fracture of the little finger. One of the very best Balkan frames I ever had was an old bamboo fishing rod that I had used quite often. It was 25 feet long, and it could be tied to the head of the bed, pulled down and tied in the desired position. If you are going to do something in regard to lining up a pelvis and getting the patient’s weight off the bed, that is another thing; but you should have in your hospital some type of bed or beds on which the patient’s bowels can move without moving the patient in any way. I am not a salesman for the Zimmer Company, but I have not seen any other bed like it for treating fractured hips, pelves or spines. You should have a good fracture table in your hospital, and you want somebody in charge of it who knows enough to oil it every day ; and you want someone to sharpen the plaster knives every day ; and someone who understands the making of plaster bandages, for they are very simply made, and it is a frightful waste of money to buy them. A nurse that knows how to do these things, who has been brought up in the business, and knows how to handle herself in a fracture 6 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 room, is an asset. We have one at the hospi- tal for Crippled Children in Newark. She will do a 5 yd. bandage in a minute, and she will do it for ah hour without the slightest trouble. You need Balkan frames. If you are going to use the metal ones, let me caution you against having an electrocution. They are splendid frames, they are absolutely vermin- proof, but there are situations — unless you keep the point in mind — where you may get your high-tension line a little too near the metal, and cause trouble. That is all the equipment you need. It does not cost much. Of course, you should have physiotherapy, but don't have to have any gorgeous display. Massage is necessary. You want some diathermy. Those are the 2 main things you need, and if you have them you can go a very long, way. RELATION OF TRAUMATIC SURGERY TO INDUSTRY* J. W. Martin, M.D., Baltimore, Md. Many interesting problems are arising be- tween industry and our profession ; especially is this true with traumatic surgery. These problems are interesting because they deal with facts facing our profession today and which we must solve. The date of conception of “industrial sur- gery” is unknown ; its birth was unheralded and its growth unnoticed, until the compensa- tion laws went into effect. The British Par- liament passed its Workmen’s Compensation Act in 1897. This attracted the attention of men in the United States who were interested in labor problems ; and while several acts were passed here which did not meet constitutional requirements, it was not until 1911 that the legislatures of Wisconsin and New Jersey passed compensative laws of an effective form. Since that time all the states except * (Delivered at the I64th Annual Meeting of the Medical Society of New Jersey, held at Atlantic City, June 13, 1930.) South Carolina, Florida, Mississippi and Arkansas have adopted compensation laws; and while there is a great variance in their interpretation, it is the intention of all of these laws to protect injured workmen and in- dustry as well. Since the various compensation laws went into effect, the attention of the medical pro- fession has been aroused because the laws provide for the collection of accounts for services rendered. This caused a competition among doctors for the business and has had a tendency to commercialize this branch of surgery, with the result that the greater part of this work has been thrown into the hands of medical men who possess more business sense than professional ability ; and industry has found that for the interests of all con- cerned it is necessary to endeavor to place in- jured employees under the care of competent surgeons and to establish control of all mat- ters of a medical and surgical nature. Con- sequently, there must come a complete and definite understanding of this economic prob- lem by industry, by commissioners of labor, by labor organizations, and by the medical pro- fession. Our profession is faced with the responsibility of giving to injured workmen efficient service at a reasonable price, and has for its reward the saving of human wastage and the avoidance of unnecessary deformities, which mean so much to the injured, to say nothing of the time saved and the large per- centage of disability avoided. The indis- criminate use of doctors means not only poor end-results or prolonged disabilities for the injured, but it is costly to industry. The general handling of industrial surgery requires more than surgical knowledge ; it re- quires an interest in the work from the stand- point of the employer, the employee and the insurance carrier. The surgeon should be able to make to the insurance carrier and to the Commissioner of Labor true and firm state- ments of a disability, without fear or favor. A man might be a foremost surgeon in his com- munity but if he does not cooperate in the proper handling of compensation cases, he will be practically worthless as a surgeon for industry. Tt is a very hopeful sign that the- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 7 best surgeons are beginning to give more of their attention to surgery of the injured, which means of course that the claimants under com- pensation laws will receive a superior class of service in the future. There are still many weak points in the surgical treatment of com- pensation cases. Our profession is going through a very close investigation by industry because our end-results in the treatment of injured work- men have not been satisfactory from an eco- nomic standpoint; and if they have not been satisfactory from an economic standpoint, they have not been satisfactory from a humane one, because these go hand in hand. Good surgical results produce good economic re- sults. Our profession is on the witness stand, as it were, and industry is asking : “Why does the same kind of a case show good results and small expense in the hands of one physician, and poor results and great expense in the hands of another?” “Why do some cases re- quire many office treatments and a great amount of physiotherapy, while the same kind of cases respond to fewer treatments and no physiotherapy in the hands of another?” Thousands of dollars are being paid for hernias which, as the result of accident during the course of employment, have' never ex- isted. To illustrate, a man was acting as a watchman and was being heckled by some children. The history of the case states that he jumped from behind a shed and said “Boo”, causing him to have a double hernia; and our organization was ordered to pay out more than ,$300 in hospital and surgical charges. The tendency to do open operations when not indicated, cases of so-called trau- matic appendicitis, and most interesting ex- amples of sacro-iliac subluxation which have Smith-Peterson or other fixation operations performed, would fill a book and take all day to talk about. Hospitals are authorized to put injured employees in private rooms when not necessary, to assign special nurses, and to take x-ray pictures out of all reason. To illustrate, a case was sent to a hospital with a clinical history of a possible fracture of a rib ; radiographs were taken of skull, spine, and chest, the cost amounting to $75. Much of the chaos found in the field of traumatic surgery is due to the wide variance of opinion ; and industry is asking why. When a person is given to several physicians to be examined, so that a true statement of the man’s condition can be obtained, the re- ports will show variations anywhere from practically no disability to almost total disa- bility. No wonder Commissions of Labor have a tendency to ignore our recommenda- tions and form opinions of their own ! I firmly believe that every injured workman should be given a liberal allowance for a dis- abling injury; at the same time, if we are to be responsible for the proper interpreta- tions of those disabilities, our decisions should lie made with a fair mind and a mature judg- ment. The term “aggravation of a preexisting condition" is not thoroughly understood by the laity and is capable of many interpreta- tions. Shrewd lawyers have taken advantage of this fact, and as a result this term is fre- quently encountered in the trial of cases which cannot stand on their own merits. For ex- ample, instead of syphilis causing delayed union of a fracture, it is claimed the accident aggravated the syphilitic condition; instead of rest in bed, following a back injury, improv- ing the heart in a mitral insufficiency, it is frequently argued that the general devitaliza- tion of the body tissue as a result of the acci- dent has aggravated the heart condition which existed prior to the accident. This phrase also benefits the malingerer; we may be mor- ally certain that the patient is not as disabled as he claims, but the Court says the burden of proof rests upon us. Unfortunately, the mal- ingerer is usually able to find some physician who is willing to support his claim; as a re- sult there is the usual difference in profes- sional opinion, the Court becomes bewildered when it finds 2 exactly opposite interpreta- tions of the issue, and the general public be- comes convinced that the medical profession wears its dignity merely to camouflage its ig- norance; for disagreement is always inter- preted as ignorance. Unless our profession confines itself to facts and accepted principles rather than the competitive juggling of s JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 theories and possibilities, our opinions will be little heeded and we will lose the respect of the public. However, the poor end-results being ob- tained for the injured workmen present our greatest problem. Much of this is due to the carelessness and indifference with which a large part of our profession regards compensa- tion cases. Men who lack special training will attempt to handle injuries coming under the compensation law which they would be afraid to treat in their own private practice. A doc- tor should know his limitations and should be conscientious enough to immediately call a con- sultant, specially trained, just as he would in his own private work; for we all know what procrastination means. As Scudder said in his oration on fractures: “By treating a frac- ture instantly, you treat the fracture; by treating the fracture after delay you treat complications. Early treatment is easy, de- layed treatment is difficult and dangerous, late treatment is lamentable.’’ During the past year we have also found many cases in which there has been improper treatment of simple wounds. The principles of proper dressings have been neglected. Oint- ments have been used on clean lacerations, making a clean wound infected. Suppurating wounds have been sealed by tight, dry, band- ages. Anti-tetanus serum has been neglected. Indifferent treatment has been given fractured fingers and toes, causing unnecessary disa- bilities and deformities. Injuries to soft parts, such as nerve injuries and the cardinal symptoms of acute abdominal conditions, have not been recognized. During the past year we have had several cases in which proper diagnosis of a severed median or ulnar nerve was not made. To my knowledge there have been 4. cases of “acute abdomen” where the patient’s life might have been saved if proper diagnosis had been made and immediate ac- tion taken. We cannot help but realize that the chief failure in our treatment of industrial injuries comes from indifference, incompetence, and delay ; and the solution lies in doing honest, efficient work. It is no longer considered •economy to organize a staff of surgeons on a basis of low fees. There is a sincere desire to give to the industrially injured the highest grade of surgical care that can be secured. Personally, I am not interested in fee sched- ides ; but I am interested in seeing that proper and efficient work is being done. For if we are doing honest work, then that work should be paid for by industry in proportion to what the injured workman could pay if he were a private patient. Industry should and will pay for such service, regardless of fee schedules or limits of compensation laws ; for naturally if good work is done for the injured, the amount of disability is lessened and in- dustry and insurance carriers profit by it. I will welcome the day when every state in the union will provide for unlimited medi- cal attention in its compensation law, with proper surgical supervision, and when there will be appointed to every Commission of Labor outstanding medical men to act in an advisory capacity without fear or favor in connection with the care of the injured, the estimating of disabilities, and the disposition of controverted bills. 1 am happy to state that the best men of our profession are inter- ested in the solution of this problem. None of us wants to see future medicine controlled by state laws ; and as our profession in the past has been respected and honored for its high ideals, I am sure that industry, Com- missions of Labor and the public will not be mistaken in the confidence placed in us to solve this economic problem. Discussion Dr. John E. Toye (Arlington): It strikes me that fracture work has become a highly specialized specialty and calls for a great deal of time. It calls for more time and more patience than the average general surgeon has to put into it. The average general surgeon looks for results and wants them quickly. He has been trained to action. He has not been trained to wait. The average fracture man, or bone surgeon, or ortho- pedist is trained to wait and take an abundance of time. For that reason I think the hospital’s fracture service should be a distinct and separate service, not because the rotating service is all wrong, but because of the time a man may be willing to put into it. As Dr. Adams has said, when you have put the bones to something near apposition, you have still done practically nothing to rehabilitate that man, and the object of frac- ture treatment is to get that man back on a wage- earning basis as nearly as possible to that which he enjoyed before. There is where time comes in. It is easy enough to put fixation on and wait for Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 9 the bone to heal; but then your time, your patience and your ingenuity are called upon to put that man back on a wage-earning basis. Just a word about physiotherapy: Until the general surgeon, who is doing fracture work, or doing industrial surgery or traumatic surgery, as you choose, follows it up as a thing worth while, physiotherapy is in danger of coming into disre- pute and falling into the hands of charlatans. It is in disrepute now; there is no question about that. Many people will say, “I have a lamp, I can take care of that at home”, which is utter rot. Of course, use of heat is a means to an end, but your massage and your constant follow-up are the means of rehabilitation of the injured man. I would like to follow Dr. Martin with a word. This is apparently going to be a “panning” party anyhow, and just now I am going to “pan” in- dustry, or the insurance companies through in- dustry. Dr. Martin said that industry is willing to pay. In my observation industry has not been willing to pay. It has delegated responsibility for the injured workman to the insurance companies, and the insurance companies have, by hook or by crook, gotten rid of doing the best possible be- cause they won’t pay the price. It is axiomatic that you cannot get something for nothing. A man who is doing special work, good conscientious work, and attempting to rehabilitate injured work- men, is not going to work for the fees which they attempt to dictate. It is not at all unusual for me to have a letter back from an insurance company, after I have presented a bill, stating that “our fee is — thus and so for this type of treatment”, but that fee isn’t my fee; I can’t do that type of work at that price, and until the insurance com- pany is willing to recognize that it has to pay for competent men — and it has to have competent men to rehabilitate the injured workmen — it is my contention that industry is not willing to pay. Dr. E. P. Weigel (Plainfield) : I think both Dr. Adams and Dr. Martin have opened for discussion a subject which is rapidly becoming more acute to all of us who engage from time to time in the treatment of orthopedic or traumatic cases. As Dr. Adams stated, the assignment of fracture cases in a general hospital service has been a matter of considerable concern to all of us. From the very nature of the case, it is inconsistent to expect that the general surgeon shall be equally adept and interested in fracture work. The frac- ture problem is becoming entirely different from the straight surgical service. I think in many hospitals it has been assigned to the orthopedic service because it more closely fits into the work than it does into the general surgeon’s work. Many of the smaller hospitals throughout the country have been unable in the past to support an ortho- pedic service because there were not enough cases of a straight orthopedic nature to warrant such a service. The usual orthopedic deformities were not in themselves large enough in number to en- list the services of a man who did orthopedic work. However, many of our smaller hospitals are today adopting a wise policy by putting the fracture service along with the orthopedic service, which enables them to maintain an adequate staff for this kind of work. I know in several of the hos- pitals in which I do the fracture work, we fre- quently have as many patients, particulai'ly on the male ward, as the general surgeons do. We have in 2 of these institutions now adopted the prin- ciple which the doctor has suggested here of the man who first starts the treatment of a fracture case seeing that case through. I do not think it is at all fair to turn it over at the end of 1 month or 3 months to another man, who possibly entirely disagrees with the treatment the first man started. I was impressed recently by a Fracture Symposium, which I attended at one of the Ameri- can College of Surgeons' meetings, to see how few of the most prominent authorities agreed on the methods of treatment of ordinary fracture cases. I think this brings out just one point: It is im- possible to standardize the type of treatment of any given fracture. Frequently hospital superin- tendents buy fracture equipment because it has been advertised as the type used by some promi- nent man, and then attempt to fit their cases to it. This is never entirely satisfactory. Every man has to use the type of treatment which in his hands has proved most successful. We all know that certain surgeons throughout the country have brought out operative methods for treatment of conditions which in their hands are successful, but it is impossible always to teach those methods to men of lesser experience and lesser surgical skill, probably with equipment they do not know how to use. I distinctly remember a position 1 held at the Post-Graduate Hospital in New York where I taught operative orthopedics on the cadaver. One of the instruments that we used was the motor saw that Dr. Albee devised, and the doctors who had come from all over the coun- try to take a 6 weeks’ course were taught the use of that motor saw. Some of the men used it well; they were mechanical by nature. But I also re- member the difficulty encountered by others. I don’t believe we are ever going to be able to standardize the treatment of fractures. A man has to use that method which in his hands gives the best results, providing he has been well trained and takes the opportunity to acquaint himself with the new ideas and new methods of men of repu- tation. I don’t think it is ever fair for that reason to turn a case, the treatment of which has been started by one man, over to another before that treatment has been finished. In reference to Dr. Martin's remarks about in- surance companies being willing to pay for good treatment, I think there are 2 sides to it. I have been told from time to time by some of the respon- sible men in insurance companies: “Doctor, we want good work. We are willing to pay for good work, and if good work is rendered we will see that you are amply compensated for it.” I be- lieve this is the attitude of the better companies. However, there are many claim agents who feel they must “shop” in medicine as they would for ordinary commodities and are still looking for cheap treatment regardless of quality. I do work for some companies that never question the bills; they want good service and -seem to think we are giving them good service, and are satisfied with our bills. However, we are constantly receiving letters from some companies requesting reductions of bills, objecting to the charge which we have made, when that charge is what we have adopted as standard for the same type of treatment. My experience has been that some companies, as Dr. Toye brought out, still want cheap work. They do not realize that they are paying a great deal more in the end than they would be by hiring a man who makes it his business to render better service, even though at an increased initial cost. I believe most companies, sooner or later, find out the men who are competent, and are willing to pay them a fair price for their services. Dr. John F. Hagerty (Newark) : I think if any argument were needed to prove the truth of what 10 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Dr. Adams has said, it lias been supplied by the pictures shown by Dr. Martin, that fractures or- dinarily are not properly cared for. In St. Michael’s Hospital until 7 years ago the fractures were taken care of by the general sur- geon, and, as has been well expressed here today, the general surgeon has not the temperament for taking care of fractures. Accustomed as he is to dealing with acute illnesses and acute infections, the general surgeon has not the temperament to care for patients whose care lasts over a very long time, nor has the average surgeon the me- chanical skill required. I think it requires a peculiar type of ability to care properly for frac- tures, and that ordinarily is not possessed by the general surgeon. We decided, therefore, in St. Michael’s 7 years ago, to set up a special fracture service, and there all of the fractures that are ad- mitted to the hospital are admitted to the care of one man, Dr. Fort, who has a group of assistants, and who cares for them properly. As has been well pointed out, in the old days sometimes* a fracture would be admitted at the close of the morning, after the surgeon had spent an arduous period operating, and he would direct somebody to see that the patient received tempor- ary care and he would look after it later; whereas, quoting from Dr. Martin, when a fracture is cared for immediately it becomes a very simple thing and easy to take care of. Dr. Frank W. Pinneo (Newark) : Dr. Adams has shown that fractures for treatment, form one, distinct, group in medicine. That brings out 2 things; the fundamental principle of undivided re- sponsibility, and yet, at the same time, the need of cooperation. Now the fear that many doctors have of fractures should not result in inadequate care of the patient nor, on the other hand, in the mistakes of the patient’s care shifting from one to another service. The demonstration that Dr. Martin has given follows up Dr. Adams admirably, and some of his remarks recall to mind what Sir Robert Jones told us in the armies, that the orthopedist must “work for function from the start”. This is con- trary to the conception that all a patient needs at First is treatment for his infection, and, after that, he can be made over again, to improve, or save from further, deformity, it being rather implied that his fracture, or other injuries, must neces- sarily involve some deformity, whereas proper treatment from the start would prevent deformity. As to the relation between industry and our pro- fession, I do not see why there should be a dis- agreement when both parties are aiming for the same end-result. We must admit that frequently the operation of the law is very faulty in substi- tuting the interest of the insurance company for the professional skill necessary. Dr. William J. Arlitz (Hoboken) : I don't know that I can add anything to what has already been said. The remarks of the gentleman “that insur- ance companies are not willing to pay” is, I think, far-fetched. There are a number of men in the room who are specializing, and whom I have called upon on various occasions to offer their best judgment and treatment in cases. The insurance companies were always willing to pay for proper services. They do want capable men to treat and examine their cases. In the Compensation Bureaus we see the end- results of fractures that have been treated by the ordinary surgeon and by the orthopedist. I do not consider the orthopedist more capable than the general surgeon. When 1 say “general surgeon”, I mean a man who is a recognized visiting surgeon at a good hospital and who is experienced. Such surgeons usually get good results. Poor results are those where the fractures are treated by men who have had little surgical experience. They all have a method of their own. Most of their methods are not good; but in the final analysis, the visiting surgeon at a hospital gets as good a result as the orthopedist. They both get good results. I know that the railroad companies — and I rep- resent quite a number of them — are always willing to pay for good service. The insurance companies, likewise, are always willing to pay for good ser- vice. They do object to huge bills for the treat- ment of minor injuries — large bills are not un- usual. We have been criticizing the results in trau- matic surgery for a great many years. I don’t think that our criticism has brought about any great improvement in methods. I don’t know how you are going to bring these about. Dr. Martin was talking about the "aggravation of a preexisting condition”, after trauma. The majority of you would be amazed if you went into a Compensation Bureau and heard these various alleged accentuations. There are a number of men here now, who have been associated with me in the defense of such cases. A man will have a small burn of the foot, and a troupe of doctors will come in, and they will allege that this man is now suffering with advanced tuberculosis as a result of that burn of the foot. Another man will have a troupe of doctors come in and say that the man is suffering with a gastric ulcer as a result of a contusion of the foot. They claim all types of aggravations and accentuations after minor injuries. I don’t know how you are going to put a stop to it. I know many members of the County Societies and members of the State So- cieties, who make these allegations. It would not be good judgment to say that all doctors who make these allegations ,are liars, because some- times trauma does produce aggravation of a pre- existing condition. A frank expression of opinion in many of these cases would not look good in the record of the case. Aggravation is so fre- quently claimed that I usually request that a specialist examine such cases in consultation. The specialist is. of course, one who has a special knowledge of the particular allegation. These ag- gravations are alleged year in and year out. I have devoted many years to these problems, but I am frank to say that with all of my experience I am unable to offer any solution for these per- plexing problems. Dr. J. Bennett Morrison (Newark): At this time I am going to ask you to recall the paper I read to you on Wednesday morning — on industrial medi- cine. I ask you to recall the plea that was made for an extended cooperation between the medical profession and the carriers in a effort to produce better results, better after-results in the treatment of the laborers in the state of New Jersey. I told you that some of the carriers were anxious to clean house and were coming to us begging for our assistance to raise the standard of surgical ability of the men who are treating those cases. I told you that some of the carriers were willing to pay your bills as rendered if it be proved that you are reputable men; that they reserved to them- selves only the privilege of referring bills which they thought excessive to those committees in the state of New Jersey which we have provided Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 11 to pass upon questionable bills; and I told you that they stated that they always paid the bill after our committee passed upon it. I can tell you instances in the state of New Jersey where in- surance companies have paid single bills up to $1000 for surgical procedures, one bill of $1200. TVe have taken this opportunity to bring to you this morning the Medical Director of one of the largest carriers in the United States. Bring him upon the floor here, treat him as you would any other speaker. Here is your opportunity to find out about the relation of your work to the com- pensation work. Let us ask him if the carriers have an association where the better class of car- riers can induce the poorer class of carriers to try and elevate their work? I am very glad indeed that the doctor showed us that series of pictures. I have been practicing medicine and surgery for the past 30 years. I do not believe there is a man in this audience, be he specialist or general practitioner, who ever had the results that were shown to us this morning. Those results are a condemnation of the class of men that the carriers pay to take care of indus- trial medicine. That is the class of work that is a reflection of the very men who are discrediting industrial medicine. That is the class of men who do the cheap work that some of the carriers want to get away from. Those pictures show in them- selves that the carriers have paid on that series of cases alone probably $100,000 more in prolonged disability and total disability than they would have paid had they employed the average competent surgeon to take care of their work. Here is an opportunity for the carriers to tell us what class of work they want, ask our co- operation in securing that better class of work, and assure us that they are interested in it and are going to pay for it when the time comes. We all know that industrial medicine is here to stay. We all know the type of men who are engaged in it. We all know the better class surgeons have been discouraged because of the number of times they are called to court, because of the ques- tion of their bills, and because of the unsatisfactory relations between them and the carriers. Now, for the next 100 years we must keep push- ing our attempts to get a closer cooperation be- tween the medical profession and the carriers. There may be faults on both sides, but the greater portion of the fault, as we can see it, is from the carriers' side. Here is an opportunity to question this man, and here is an opportunity for him to lay his cards on the table and tell us what he wants us to do in order to better this condition. Dr. Maurice S. Avidan (Newark) : I have been associated with the State Department o'f Labor for several years and, having had the opportunity to review a large volume of this work, I should like to present certain facts. In the first place, the type of fracture and other industrial work that is being done in this state at the present time is far better than it has ever been before. This includes the work from the general profession at large. One reason why the work has made such an improvement is because of the fact that there has been created a very important depart- ment relative to industry, which is a sort of clear- ing house for all industrial work, called the Com- pensation Bureau, through which medium a check- up can be made of the character of work of each man engaged in the practice of industrial surgery. Each case of any importance must pass through this Bureau and its functional end-results are made a record and evaluated. This is done by careful studying of each case from purely a medi- cal and surgical standpoint, including clinical, pathologic, x-ray findings and prognosis as to function. Consultations and conferences in the more serious cases have been of great value in determining this factor. A public record is made of each case. I have always felt that the fracture work should not be taken away from the general surgeon. I have seen some very good results among the gen- eral practitioners and have also seen some very poor results among the industrial and bone spe- cialists. I think that the general practitioner who is conscientious and who knows his limitations is very capable of handling this class of work. I also think that some of our bone specialists are at times a little over zealous and often too radical, especially in the open operative field. After all, industry demands good functional re- sults with the least amount of lost time. Dr. Martin demonstrated some very poor results in fracture work. I do not think that is the type of work that is found in New Jersey; and if some of these poor results should be found, then indus- try and the insurance carriers should have no complaint, because they have full control of the medical situation, as to choice of doctor in each particular case. They have taken advantage of that right under the Act and have been given full sway in making their choice. Dr. Martin stated that in his opinion there should be . no question about the payment of medical bills if the work is properly done. Dr. Martin represents one of. the largest1 insurance companies in the country and it is very gratifying to the medical profession to know this. From my experience I believe 90% of the insurance companies have co- operated and have done fairly well, everything be- ing taken into consideration. They frequently come to the State Department for suggestions and advice concerning special treatment. Therefore, I don’t think that they ought to be unnecessarily criticized. However, a few of the companies in the last few years have tried to take advantage of some of the doctors; but in the long run they have not succeeded. Quite often the doctors have had grounds for criticism, but in the large ma- jority of instances it was due to misunderstanding. One of the greatest problems we have to deal with in this state, and one which cannot so easily be solved, is the question of expert medical testi- mony in compensation cases. As Dr. Martin stated, one expert will state that a man has 10% loss of function of a limb and another will state he has 80% loss of function. In these instances we are compelled to resort to courts and to have laymen decide questions that are purely medical in nature. It has become a serious problem because it puts the medical profession on the defensive and very often in a very embarrassing position. There are members of the medical profession who make a specialty and have no other form of prac- tice than giving expert opinions on disabilities in courts. There has been an attempt to overcome part of this perplexing problem by urging medical conferences and consultations; which in many in- stances have proved successful, especially where there was wide difference of. opinion. Dr. Henry II. Kessler : I just want to add a little note of optimism and sort of second the statement just made by Dr. Avidan. About 10 years ago we used to see those same results which you saw on the screen a fe’jv moments ago; but fortunately we do not see them now. I am quite 12 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 sure there has been a marked improvement in the end-results of the treatment of fractures, both by the orthopedist and by the general surgeon. How- ever, I do think we should aim toward a definite goal regarding the general relationship between the cax-riers, industry and the medical profession. I feel there has always been a spirit of conciliation between the various groups. Today, at least in the northern part of this state, we do not see indus- trial surgery or traumatic surgery in the hands of a very few. There has been a tendency on the part of carriers and industry as a whole to dis- tribute the work rather evenly among the general practitioners and surgeons. As a general rule, the bills that come from com- petent men, men who are on the surgical staffs of recognized hospitals, are rarely questioned. Then, of course, we have a different set-up, of which I will tell you this afternoon which helps in the adjustment of medical differences. I would like to see a special fracture service in hospitals. I am in accord with the previous speakers on the subject. At the same time there is still room and still an opportunity for the gen- eral surgeon who is interested in fracture work to get aboard the bandwagon. No better instance can be pointed out than the fracture service at the Massachusetts General Hospital. There you see orthopedic surgeons and general surgeons co- operating in performing some of the finest frac- ture work in the country. Dr. J. K. Adams: First, Mr. President, I did not mean to state — I don’t think I did state — that I wished any differentiation whatever in the treat- ment of fractures by general surgeons or by or- thopedists. If Dr. Arlitz understood me to say that, if he thought I said the fracture services were not properly handled by general surgeons, he is mistaken. What I stated was that there should be a fracture service established, that is, that the rotating- type of service should be abol- ished. Yrou could call it a “traumatic service”, or a “fracture service”, or you could call it any kind of service you wanted to; but I have made no •differentiation whatever between general surgeons and orthopedists. I even went further, I said let anybody treat the fractures who wants to treat them, but make someone responsible. When Dr. Hitchcock presented his paper on this subject, which was the most illuminating I have ever heard or expect ever to hear, he distinctly ended his argument by stating that if he had a severe, compound, infected fracture of the femur, or any other long bone, he would rather be treated by a good, earnest conscientious man who under- stood the principles of what he was doing than by the 3 greatest stars who ever lived; and what he was referring to was the rotating- service. That is my point. In this fracture business we go through fads. We do things because it is the style. You will remember that about 20 years ago we were going along in the same old routine way when Arbuthnot Lane, of England, made a visit to America. He was the master of a per- fectly extraordinary technic in the application of medical plates to bones; the result of years and years of extensive study and splendid concentra- tion: a technic that was impossible for the aver- age man ever to approach. Within 6 weeks after he arrived, the steel mills were busy turning out plates to put on broken bones; and some of the results were perfectly frightful. Not only were these plates put on patients who did not in any sense require them, and who could have been treated by a closed method perfectly well, but it was the style to use steel plates — and the Lord knows they were used in America, there is no question about that. Now, as to what Dr. Toye said about the general surgeon being unwilling to wait, or not being trained to wait, and what he said about the or- thopedist being more or less trained to wait is, I think, true in a certain sense. The orthopedist has naturally been forced into a waiting attitude as the result of a great deal of bone pathology that has come under his attention, such as tuberculous spines, and tendon transplantations followed by long periods of muscular education. I think that is true. It is natural for a man who has been brought up to play cricket in England to spend 3 days playing a game; while in America we want to see a ball game in an hour and a half. We are not accustomed to have a man go to the bat and take 3, 4 or 5 hours to make 150 runs; we expect him to do something right away, either strike out or get on first base. In regard to this insurance company proposition: we all have had our experiences from which to form our opinions. Naturally, the opinion we have is the result of our experiences. If you have sent 150 bills to insurance companies in a certain length of time, and every insurance com- pany has sat down and sent you a check promptly, you do not feel that there is anything to com- plain about.; but when a great many insurance companies on a great many different occasions refuse to pay your bills, why then you don’t feel that insurance companies have exactly rushed for- ward with money. That is the point. I have had some of those experiences, I must admit. I even had an instance where an insur- ance company wrote me that my bill was too low, and sent me a check for a higher figure. But that was only one instance! (Laughter.) I think 1 sent them a bill for $25, and they thought the result was very nice indeed, and that I had under- charged, and sent me a check for $50; but that isn’t a daily occurrence. That is what I want to bring out. Now, these are exact facts, and there are men here who can back me up on them. My experience has been somewhat like the experience of Dr. Toye. A man was struck on the back by a heavy hoist that was lifting a large stone. He was com- pletely paralyzed below the waist. He was brought into the hospital. A careful examination was made and it was found that he was totally paralyzed be- low the point of fracture, which roughly was somewhere around the first lumbar vertebra. He had absolutely no control of the bladder and no rectal control ; no sensation whatever below the waist. He was in very decided pain. I was asked to see him by the physician for the company for which this man had worked. He told me that he wanted me to see the man, and he wanted me to suggest a treatment to have carried out, that he would be prepared to assist in carrying it out, and if he was not able to do it alone would get some one to assist him, and that he had au- thority from his company to ask me to see the man. I saw the man. We made the examinations, we x-rayed him, and found he had a fractured spine, naturally. It was not quite so bad as we had thought. This man was put up with a head apparatus with traction on it, and -with traction on his feet also. He did not do well. I saw the representative of the company, who was an ex- ecutive of that company, in that hospital with a great many of this man’s relatives and friends within a few days, and they wanted to know what I thought about his condition, and I told them very plainly that I thought the man was very Jan., 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 13 seriously injured, that I did not think that he would ever walk again, and I questioned whether he would live. Well, that was discouraging, of course. Now, this accident, while I will not say that it was absolutely the fault of this company, I know that the company felt that it was a little to blame because the representative told me so, or intimated that it had not taken the safe- guards that it should have taken to prevent that accident. The representative asked me if I would mind having someone else see this man in con- sultation with me. I said: “Certainly not. Have you anybody in mind? You can have anybody that you want see this man, anybody that you think can be of service or of the slightest assist- ance.” In the course of the conversation the name of Dr. Albee, of New York, was suggested as a proper person to come and see this man in re- gard to what the probable outcome of the case would be and as to what the treatment should be, the subsequent treatment. Dr. Albee said he would be very glad to come, and he did. Fie made a very thorough and careful examination of the man, and said he had nothing whatever to sug- gest in regard to the future treatment. He said he would come again in 6 weeks and see the man and ascertain whether he was doing well, and that the advisability of what should be done would, of couse, depend on what the examination revealed at that time. Now, I saw this man 5 or 6 times, went a considerable distance from where I live to see him, and he was being taken care of daily by the physician of this company and another physi- cian had been called in to assist him. He had a number of radiographs, and his board was being paid in the hospital by this company. At the end of about 3 weeks the man died, and the physician who treated this man sent in his bill. It was a larger bill than mine, very much. It was paid. The other physician who assisted him sent in his bill. That was paid. The x-rays were paid for. The hospital was paid. Dr. Albee was said to have been paid, and I think he was; at least this man said so. I sent this representative a bill for $100. As I said, the patient was seen by me 5 or 6 times, and I went an appreciable distance to see him. I did see other cases when I was there on most occasions, but on 1 or 2 occasions I went up there just to see him. I got a letter back from the insurance company saying: “We don’t see why we should pay your bill. We would like you to write a letter in explanation of your bill and send it to the State Department of Labor and explain why you have sent us this bill.” The executive of this company who saw this patient with me, and who saw him in the presence of his relatives, stated in the presence of these relatives that there was no expense whatever that this company would not pay to put the patient on his feet again if it was humanly possible. I wrote Dr. Avidan a letter about this matter and asked him what to do about it. He replied that he would be very glad to take it up, that he would write to the insurance company, but he said, “We have no authority to make them pay, but I will be very glad to write a letter for you and see what can be done in the matter”. Flave they paid? No, they have not, and I don’t suppose they ever will un- less I sue them. Now, when you tell me that in- surance companies are always glad to pay, do you wonder why I disagree with you? Dr. J. W. Martin : I did not know I was going to get into a commercial argument here today. I am not going to hold any brief for insurance companies. Up until a year ago I had the pleas- ure of being a doctor myself. It is true that in- surance companies do have claim departments which try to get you down to the last cent. I did this work until a year ago, and I was tremen- dously interested in traumatic surgery. I will have to tell a little about myself. I know how the medical men do not get together as a unit, but act as individuals, and the one fellow fights the other, and how the Claim Departments, if they can, will whip you down a dollar. So, when I went into this Department, I said, “We are not going to have any fee schedule, and the Medical Depart- ment is going to run as a separate unit, not con- nected with the organization”. And that is true as far as this company is concerned, and that is all I am interested in. If men will charge a reasonable fee, or charge the insurance companies what they would charge in that case were it a private patient, insurance companies would pay for it, and they would pay for it without any trouble, and they would pay a whole lot more than would a private individual because a private individual could not afford to pay the economic value that the insurance com- pany could. They are dealing in dollars and cents; but it so happens if they deal in dollars and cents, we are dealing with the human side of it, and the two go hand in hand, as I tried to bring out in my paper. Now, these end-results — they were not from New Jersey, but they were from different states in the Union. I do not think, Gentlemen, from looking over the files and records in the United States, we are doing good work. It is not because we do not know better; we are indifferent to it. It is up to you to get behind this thing and say to the insurance companies: “We are going to give you the best there is, and you are going to pay for it.” Dr. Weigel (Plainfield) : May I ask Dr. Martin just one question? He has said in his rebuttal, as it were, that if the doctors would charge the in- surance company for the treatment of cases what they would charge ordinarily to individuals if the individual was to pay the bill himself, the insur- ance company would very gladly pay that much or possibly more. Now, it is my understanding of the average compensation law that it was put into effect for the very reason of giving that man some compensation and paying for his treatment because he was injured while in the employ of whoever happened to have hired him. I think everyone of us feel that if these men were in- jured When not working for the company employ- ing them, they would all be charity patients on the ward service. Invariably, these laborers are the heads of large families, who can’t pay a sin- gle thing for their treatment. The same man if he is injured after his work on his way home, for instance, by an automobile, pays the doctor ab- solutely nothing for his services; and it seems to me that if the insurance companies are going to tell us that we should charge for these services just as we would charge him as a private indi- vidual, we would have to treat every case for nothing. Dr. J. W. Martin : I don’t know how to make myself clear, but I don’t see how I can make it any plainer than this: What is going to be the ordinary charge for a broken femur for a man who is working at $4.50 per day; and, we will say, who has a family to support? You say he goes into the ward and you don’t get anything. Well, I imagine that $150 or $200 would be a good price under those circumstances. 14 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY •Ian., 1931 Ur. Weigel (Plainfield) : Yres, but the man could not pay that. Ur. ■] . W. Martin : But the insurance company would pay you. Now, as far as the compensation law is con- cerned, I tried to bring out in my remarks that I would welcome the day when a universal com- pensation law was adopted. Down in some of the Southern States, for instance, a man has a broken leg. The compensation law says $100. Well, how long does that last? As long as a snowball in some place. The fellow has still the fractured leg, and it must be taken care of. Industry must be philanthropic, because if they let that leg go im- properly cared for. then they are going to have a tremendous amount of disability; therefore, they cannot recognize your compensation law, they have to pay several hundreds of dollars for the care of the case, and willingly do it because if they get a good result it is cheaper for them. However, our troubles are we don’t know what charges we are to make. 1 think that is the trouble. One of us might think that our time is worth a whole lot of money. Well, if it is, then don't fool around with this sort of work; but if you can take it in along with your practice in a general way, and get a general fee for it, all well and good. I will say frankly, from a commercial stand- point, for every dollar that this company takes in — and I believe it is the same way with all com- panies— they are spending $1.50, so they are not making any money on it. My Department alone spent $2,000,000 to the medical profession of the United States, anu, therefore, I believe that the insurance companies are giving a little money to the profession. Fig. 1. Chairman McBride : We have had a very splen- did morning. These papers have all been very worth wrhile, and I want to thank at this time the speakers who presented them, also the discus- sants. It has been very illuminating, and I be- lieve we have gained knowledge by their presenta- tion and discussion. GASTRO-INTESTINAL DISORDERS IN RELATION TO DEFECTIVE GASTRO-INTESTINAL MECHANICS* Charles Gilmore Kerley, M.D., New York City That gastro-intestinal disorders of widely varying types may be occasioned by faulty structural gastro-intestinal relations in the adult has been known for years. It has been known that displacements, dilatations, angu- lations and peritoneal bands have a pro- nounced effect upon function; that similar * (Lantern Demonstration at the lG4th Annual Meeting of the Medical Society of New Jersey, Sec- tion on Pediatrics, Atlantic City. June 14, 1930.) 1. Iliac Crest. 2. Stomach erect lower margin. 3. Transverse colon erect lower margin. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 15 conditions might exist in a child has received but scant attention. The child is given the credit, without investi- gation, of being structurally normal except in such strikingly apparent conditions as pyloric disturbed physiologic function in which the matter of food and chemistry is emphasized. Further, the young child, because of lack of development, is prone to nerve imbalance — a systemic failure of coordination. This ap- Fig. 2 -A. stenosis, imperforate anus or other gross anomalies. It has been, and is, largely the medical habit to attribute all types of gastro- intestinal disorder in infants and children, from vomiting to constipation, primarily to plies particularly to that part of the baby which comprises the gastro-intestinal tract, where function is entirely under the control of nerve impulses. Imbalance and incoordi- nation of the independent parts of the gastro- JOURNAL OF THE MEDICAL SOCIETY OF NEW JH RSEY Jan., 1931 ] G intestinal mechanism explain many of the functional gastro-intestinal disorders of early life. During the past 20 years I have in different contributions called attention to the depen- dence of many gastro-intestinal ailments in children on defective gastro-intestinal mechan- ics. The nature and some of the results of a loss of appetite in the infant or young child? The answer — presence of food in the stomach; food retention beyond the time when it should have passed into the intestine. Hunger pains do not occur in a partially filled stomach. I have investigated a vast number of these loss of ap- petite cases through giving a test normal breakfast, consisting of milk, cereal, perhaps Fig:. 2-B. poorly functionating gastro-intestinal ma- chine comprise the aim of this contribution. General practitioners and pediatrists are con- sulted daily by parents concerning children in whom the chief complaint is habitual loss of appetite ; often with associated symptoms of eructations of gas, stomach pain and, in many, habitual vomiting. What is the outstanding cause of habitual an egg or bacon and a breadstuff, and then by means of a stomach tube determined the pres- ence or absence of retained food, 4 hours or more after completion of the meal — repeat- edly finding food residue 5-6 hours after the meal. Fig. 1 demonstrates a girl, Sl/2 years of age, who had persistent loss of appetite with food retention 5 hours or longer after Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 17 a meal. In nearly all of such children there is a mucous gastritis which can be demon- strated by the thick mucus removed from the stomach — shown in the illustration suspended on wood applicators. This child’s food re- Fig. 3. tention after 5 hours varied from 1-3 oz. I feel that the retention is caused by pyloric spasm, due largely to gastric hyperacidity, i Hyperacidity of the gastric contents in chil- Fig. 4. clren — Jour. A. M. A. Nov. 25, 1922 — by Kerley and Lorenze.) The thick mucus possibly acts as a plug to the pyloric opening of the stomach. The management in a case of this sort is re- peated stomach lavage at least 5 hr. after eat- ing. An ordinary 3 meal a day diet is allowed, with the exclusion of fat and bananas; these substances are invariably a part of the reten- tion if given to children in whom this feature is prominent. Fig. 5. In Fig. 2 is shown a girl, 11 yr. of age, who came to us because of a persistently poor ap- petite and habitual constipation ; eructations Fig. 6 -A. of gas and food were of daily occur- rence and vomiting was fairly frequent. The relative positions of the stomach and colon in the erect posture are shown. The lower bor- 18 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 der of the stomach in a child of this age should be 1 in. above the umbilicus. The ptosed stomach is mechanically inefficient, a slow working organ. Cases of this type also show high stomach acidity and usually mucous gastritis. In Fig. 2-A, the position of the stomach is indicated, according to the x-ray findings. The constipation can in this instance be ac- counted for by the ptosis of transverse and descending colon and sigmoid ; demonstrated in Fig. 2-B. Management. The first step in treatment of a case of this sort is to prevent a stomach over-load ; but small amounts of fluid can be given with a meal, and after a meal the child should remain recumbent for 2 hours. Water Fig. G-B. is given sparingly, and not over a pint of milk is allowed in 24 hours. Soups are excluded from the diet. A powder composed of atropin sulphate gr. 1/300, magnesium carbonate gr. 1. bismuth sub. carb. and sodium bicarb, each gr. 2. is given 10 minutes before meals. Parents are instructed to avoid condiments, cold drinks and iced foods. A 5 hr. interval feeding plan is invariably followed, with no food between meals. Cases of ptosis in- variably make a more rapid recovery if a belt (Fig. 9) is worn during the time the pa- tient is up and about. For the constipation a dessertspoonful of mineral oil is given at bedtime and aromatic fluid extract of cascara Yz teaspoonful after each meal. Fig. 3. Chronic appendicitis may also in- fluence stomach emptying. In these cases we find food retention, lack of appetite, recur- rent vomiting, periodic pain and frequently malnutrition ; constipation alternating with diarrhea is frequently present. The illustra- tion demonstrates bismuth in the appendix 96 hr. after the bismuth meal. The appendix in this patient was removed a few weeks after the x-ray study and was found badly diseased. Recurrent vomiting is frequently due prim- arily to defective mechanics. A boy, 4 yr. of age, came to us because of repeated vomiting attacks which had occurred about every 3 months for a period of 2 years. The Fig. 7. attacks were very severe, producing much loss in weight and dehydration to the degree of necessitating glucose solution intravenously and subcutaneously. In Fig. 4 is shown the spastic colon of this patient 72 hr. after the bismuth meal; the bismuth meal being held for this period of time by the spastic colon. The child suffered from obstinate constipation, and daily enemas were required in addition to co- pious doses of mineral oil. This child repre- sents the extremely neurotic type of individual, manifested in the intestinal tract by exagger- ated nerve impulses associated with imbalance Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 19 and incoordination. In this patient, under diet and hygienic measures, atropin to the point of physiologic effect, together with mineral oil and the aromatic fluid extract of cascara ad- ministered 3 times a day in doses of ^ dram, relief of constipation and recurrent vomiting- seizures was effected. Intestinal stasis of this type invariably produces food retention in the stomach beyond the 5 hr. period. Fig. 5 demonstrates the stomach of a boy, 6 yr. of age, who suffered from violent stom- ach colic. The illustration shows the stomach in active hyperstalsis with spasm at both the Fig. 8. pyloric and the cardiac orifices. Because of the double spasm, particularly at the cardiac end, the child could not secure relief' by vomiting. Localized circular fiber spasm may occur at any point between, and including, the esophagus and anal sphincter. Fig. 6 A-B. This patient was an infant, 3 months of age, of the spasmophilic type who was brought because of severe colic. The illus- tration A shows marked muscle incoordina- tion and circular fiber spasm. Illustration B demonstrates complete coordination both longitudinal and circular fibers in violent action with immediate forcible evacuation. Nerve imbalance and defective coordination of the independent parts of the gastro- intestinal mechanism explain the colic in this case, and colic in general in infants and children. An important point to remember is that pain ( col- ic) due to nerve imbalance and muscle inco- ordination is apt to be much more severe than pain due to pathologic states — more tempor- ary in character, and is further indicated by acute paroxysms of pain and sudden relief. In our radiographic studies we have demon- strated 2 types of colic — stomach colic and that of intestinal origin. There may be var- ious remote causes but the immediate cause Fig. 9. ot the pain is the formation of gas block due to muscle cramp, localized circular fiber spasm with hyperstalsis of the blocked gut areas. This infant had been carefully fed and no change was made in the food formula. Atro- pin. 1/1000 gr., was given immediately before each feeding ; with an immediate cessation of the colic. Ordinarily, these colicky infants re- quire food adjustment, stomach lavage and often-times dilatation of the anal sphincter. Constipation and delayed bowel evacuation can be readily understood by study of the constipation group which follows: , Fig. 7 represents what may be looked upon as a normal colon in a child 2 yr. of age. 20 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Fig. 8 compared with Fig. 7 demonstrates at once the cause of the obstinate constipa- tion from which this child suffered. In cases of this sort, evacuations are invariably de- layed. An elongated redundant colon ex- plains the delayed evacuation in the great ma- jority of children studied by means of x-rays. Any factor that causes delay in emptying of the colon is very apt to postpone the emptying time of the stomach, with consequent loss of appetite. The management of cases of this type comprises the use of the abdominal belt, mineral oil, aromatic fluid extract cascara in sufficient dosage, usually jA dram or more 3 times daily after meals, to produce 1 or 2 free evacuations daily. X-ray studies of ptosis cases demonstrates that a decided support is sup- plied to the gastro- intestinal structure by the use of the abdominal belt (Fig. IX). In about 75% of the gastro-intestinal dis- orders of infants and children are found due to defective gastro-intestinal mechanism. There- fore, every patient with a gastro-intestinal disorder, with a history of chronicity, who re- sists the usual common sense dietetic manage- ment and properly directed medical measures, is given the advantage of a complete gas- tro-intestinal study by means of radiography. Discussion Dr. Percival Nicholson (Philadelphia) : I have been interested in this subject for many years. Dr. Kerley brought out some very important points. One was in regard to chronic appendicitis, which was very interesting. I have seen in the last 18 months about 7 cases of appendicitis that only showed spasticity of the colon. They all showed very definite and distinct changes in the appendix. Some had adhesions with complete obstruction at the end, and the children had a very uneventful convalescence. I should like to ask if he has taken any blood calcium analysis in the spastic types to determine whether these patients had any low blood calcium, with regard to administration of calcium as a means of lessening spasticity. Dr. F. I. Krauss (Chatham) : I feel that a pupil requires a great deal of temerity to discuss the paper of his teacher. Some thoughts occurred to me as Dr. Kerley was reading this paper and show- ing his radiographs, and I wish to ask him for further discussion. First of all, the question of loss of appetite in children, or poor appetite, which usually begins after they are 1 yr. of age, is due to 2 factors: first, the physical factor which Dr. Kerley has portrayed, and secondly a mental one, the influence of the mother on the child, that is, her influence in trying to force too much and too frequent feedings. We are hearing so much to- day of mental hygiene that we must be careful not to lay too much emphasis on this mental side, but must remember the physical side which is also very important. I believe that many cases of poor appetite are due to the frequent feeding of infants, especially with sweet milk. I have noticed in keeping chil- dren on lactic acid and lemon juice milk for the first year that, when put on sweet milk, they very frequently begin to lose appetite or to have such symptoms as the doctor has spoken of. In several of these cases I have gone back to lactic acid or lemon juice milk and have kept it up even during the second year, with relief of symptoms. The second cause is rickets and the loss of muscular tone, particularly the lordosis due to rickets in the first year. A third cause might be due to the general ptosis because of the upright posture assumed. There is a tendency to forget that the child must rest after meals. It leaves the table and runs about, and immediately there is a drag and weight on the stomach and intestines to which it was not formerly accustomed. I have found that having these children rest after each meal is a very im- portant factor in correcting the conditions. Dr. Kerley has brought out that these cases are due to too much sweet milk in the second year of life. We cannot go back to acid milk until we have relieved the fermentative condition if it is at all severe. In treating cyclic vomiting I thought at one time that it was due to too much fat and my routine was to put them on skimmed milk, take away butter, etc. I found a certain proportion of these children went on with their attacks. I had not taken into account the fact that these children had ptosis, and had a great deal of heavy mucus in the stomach; it was often more im- portant than the amount of fat that was being consumed. Another point is that pylorospasm does not stop in infancy. We think of it as occurring in the first 6 months of life, but, as the doctor has brought out, many of these children up to 6 and 7 years of age have a tendency to pylorospasm. If we treat them as we do in infancy there is re- lief. My greatest friend in the practice of medi- cine for children is atropin. I have it made up in tablets of 1-.1000 gr. and dispense it rather than send a prescription to the druggist because I do not know where the druggist buys his atropin. and so many times if prescribed in solution it is kept too long and has deteriorated; I make a prac- tice to give it at the office as long as I want the child to have it. We should take more radiographs. It is remark- able how few x-ray pictures of the gastro-intes- tinal tract are taken; and it is not a difficult thing. They bring out just these points that Dr. Kerley has mentioned and I feel as he does that if we do not do this we are practicing the medicine of 30 years ago. Dr. Charles G. Kerley (closing) : It is quite im- possible in a contribution of this kind to go greatly into detail. My time allowance only permitted of referring to essential points. Retention of food in the stomach may be due to causes relating imme- diately to the stomach, such as spasm at the pylorus, mucous plugs and malposition, and to re- mote influences such as delayed emptying of the intestine or inflammatory conditions in any part of the intestinal structure. The most frequent remote cause is constipation, regardless of whether it is due to the spastic gut, to ptosis, elongations or angulations of the descending colon and sig- moid. An important feature, therefore, in reten- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 21 tion cases is free bowel evacuation. I see to it that 2 evacuations occur daily, when bowel in- activity is the apparent cause of loss of appetite due to stomach retention. Among- the food substances that are slow in leaving the stomach, fats of all sorts and ba- nanas stand out prominently. Atropin is of great value in all cases of gastro- intestinal spasm re- gardless of the location. It must be used in full dosage, to the point of physiologic effect often- times. Probably three-fourths of the digestive ailments of infants and young children are due primarily or remotely to defective gastro-intestinal me- chanics. This applies equally to the acute as well as habitual derangements. CHANGES IN HUMAN RICKETS AFTER VIOSTEROL THERAPY* John Caffey, M.D., New York City Fourteen cases of severe and moderately severe rickets were studied clinically, chemi- cally and roentgenologically, before and after administration of viosterol therapy. The be- havior of these rachitic patients varied con- siderably and the group studied is not large enough to warrant general conclusions, but 16 lantern slides were shown depicting the changes after viosterol in individual cases. One or more examples of the following types of reaction to viosterol were demonstrated in each picture. (1) Appearance of the “line test” for healed rickets, in x-ray films, after 14 to 21 days in the usual care of rickets on adequate viosterol dosage (20-30 minims daily). (2) The increase of lowered serum phos- phorus concentration to normal after 7-14 days of viosterol therapy in the usual care on adequate dosage. (3) In high calcium rickets, a depression of the abnormally increased calcium to normal concentration before increase in the depressed phosphorus concentration began. (4) Rapid increase in the lowered calcium concentration, and rapid disappearance of clin- ical symptoms of rachitic spasmophilia, after adequate viosterol dosage. Calcium concentra- *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Section on Pediatrics, Atlantic City, June 14, 1930.) tion became normal after 48 hr. Laryngo- spasm in 1 case disappeared after 24 hr., and Chvostek’s sign subsided after approximately 96 hr. in a second case. (5) Persistence of craniotabes for 30-40 days after adequate viosterol therapy and many days (10-20) after the “line test” for healing had become positive in x-ray films of the long bones, and after serum phosphorus- concentration had increased to normal and the product of the calcium plus the phosphorus exceeded 40. (6) Marked clinical improvement occur- red in all cases which showed chemical and roentgenologic healing after viosterol. The clinical improvement was manifested chiefly by increased activity and gain in muscle power, improved disposition and appetite, and gain in weight. None of the patients was definitely anemic, nor did any of them show enlarged spleens previous to viosterol therapy. (7) A few patients treated with inade- quate amounts of viosterol (5-10 minims daily) showed a greatly retarded response to viosterol and 1 showed no signs of healing after 40 days. (8) The results with viosterol in this group of rachitic infants approximate those previously reported with cod-liver oil and ultraviolet light therapy. Discussion Dr. Stafford McLean (New York) : I quite agree with Dr. Caffey’s statement regarding the favor- able effects of viosterol therapy in rickets as shown by x-rays. It is a helpful piece of academic work. That rickets is a very important disease needs no argument and any accurate observations on the results of new therapy are of value to all of us. Dr. Caffey has asked me to show some x-ray pictures of healing with cod-liver oil, for in spite of the favorable changes in chemistry, and healing as shown by the x-ray with viosterol, we are both very cautious When teaching medical students about the use of viosterol. YVe stress that suffi- cient evidence has thus far not been obtained re- garding indications for the use of viosterol except possibly in certain types of cases, and that for general use either for prevention or cure it is not a substitute for cod-liver oil. It was formerly thought that rickets was present only at certain age period. I have a radiograph in m'y possession of an infant taken on the first day of life by Dr. Maxwell of Pekin. The mother had osteomalacia and this infant showed definite x-ray evidence of rickets at birth. This child was cured roentgenologically by giving the mother, who was nursing the infant, viosterol. At the end of a month there was marked evidence of healing. We have seen x-ray evidence of rickets at 6 weeks 22 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 of age in New York, and I have seen autopsies on infants 2 months of age who showed microscopic evidence of rickets. Rickets in our experience may occur in the second and third and fourth and oven fifth year of life but in decreasing frequency. (Slides shown.) Dr. Blanchard : Do you feel as the result of your observation that it is better to give some cod- liver oil routinely with viosterol? Dr. Oaffey: Yes, I think it is better to give cod- liver oil with viosterol. If you want another sub- stitute for the vitamin A content, egg yolk con- tains vitamin A in high concentration. We have given viosterol in large dosage with no signs of lack of appetite. Large dosage in our experience does not seem to have any untoward effect. SOME ODDITIES IN ACUTE MASTOID DISEASE* W. L. Pannell, M.D., East Orange, N. J. To a body of men so widely experienced in clinical and operative otology, it is scarcely possible to introduce a single oddity that has not previously been met. Nevertheless, this Section might care to consider, by way of diversion, any little oddities incident to aural practice, and which go to make up the larger horizon for the otologist. Dwelling on the peculiarities of a disease, however, a grave danger lurks in the possible habit of missing the bigger issue. It is on this score that we feel some reluctance in appearing to capitalize items of important but often of wayside in- terest. Perusal of literature on the atypical reveals interesting points of view, and one could not do better than quote the words of 3 recog- nized workers in our specialty : Benjamin Schuster, discussing Ersner’s paper on aty- pical mastoiditis, stated that were he to write a book on otology he would endeavor to teach the student even more about the atypical than the typical mastoid. The late S. Macuen Smith, in a paper read before the Southern Medical Association, emphasized the tragedy resulting from unrecognized or atypical forms of mastoid disease. Frank Allport, being ♦(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Section on Ophthal- mology, and Otorhinolaryngology, Atlantic City, •Tune 13, 1930.) asked to discuss T. H. Harris’ paper on aty- pical mastoiditis, demurred somewhat on the ground that he had met so many atypical cases that it had become hard for him to know what constituted the typical. Apparently, we are brought up on the ortho- dox mastoiditis of text-book writers, only to be asked to bolt to some extent time-honored points of diagnosis. A friend practicing otology said that in his intern days all was definite and clear to him, whereas after 20 years of experience in a busy clinic he had learned that practice was a great amender of early ideas. The mastoid appears to intrigue one with the simplicity of its signs of disorder. As time goes on, however, the student is slowly but surely undeceived. The first recorded mastoid operation was performed in 1740; Jean Louis Petit, a gen- eral bone surgeon, having that distinction. Nearly 100 years elapsed before any treatise on otology appeared — that by Itard — and peculiarly enough, the first clear description of mastoiditis did not appear for 2 more gen- erations, waiting on Friedrich Bezold to chart the signs of that disease. After nearly 200 years of mastoid surgery it is noteworthy that there is still discussion as to the relative value of symptoms calling for surgical intervention. Of the many odd things that are informally talked about by our associates in an ear clinic, it is a jolt to me to discover that a thing that is important enough to make conversation be- tween friends falls far short of the require- ment for such an occasion as this. To sift out the experiences that might be of most interest to you is indeed difficult, and pre- sumes your indulgence. Mackenzie has hinted that unusual anatomy may be responsible for atypical disease, while G. E. Roberts states that strange anatomy is sometimes baffling to the surgeon. Accordingly, it may not be amiss to consider for a moment the anatomic side of acute mastoiditis. Of the structures in close relation to the operative area, the facial nerve may, by a rare chance, prove of importance both symptom- atically and surgically. Alderton, in his series of specimens, found that the facial canal varied in depth from the suprameatal spine Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 23 11-20 mm. Likewise, variation of nerve posi- tion in the region of the oval window was marked, considering the small size of the sul- cus through which it passes. Toward the stylomastoid foramen the path may vary suffi- ciently from the normal to invite trouble, es- pecially if the surgeon follows the sigmoid too far toward the jugular bulb. Byrd speaks of noticing the facial in an anomalous position while making the primary groove in a simple mastoid operation. A study of the bony canal in Alderton’s opinion does not reveal de- hiscences in many instances. Early palsy in acute otitis media may come from the sur- rounding cells or through a breach in the canal itself ; the latter statement is disputed by Politzer. A boy aged 16 came to the clinic with a strange facial expression, voluble type of speech, and history of double acute mas- toiditis 6 months previously. Double facial palsy comes under one’s notice rarely, and reference to this case may .be appropriate under the title of odd things that may be met. On the anatomic side of our oddities by far the most interesting seem to relate to the lateral sinus. Seymour Oppenheimer gave some interesting data on this venous channel in connection with his research, on the venous system of the temporal bone. He cited an in- stance where the emissary vein was quite as large as the lateral sinus. This recalls the dis- secting room experience of J. C. Beck; find- ing 2 sinuses on the same side. Allison T. Wanamaker, in his recent article on sinus thrombosis before the “Triological” society, incidentally mentioned that the right sinus was usually larger than the left and more sus- ceptible to involvement. While the position of the sinus is a problem in chronic mastoid disease it may also occupy an unusually for- ward position in acute cases even where there has been no preexisting inflammation to re- tard development of the mastoid cells. Throm- bosis might be expected to occur unusually early in such an instance. A case comes to mind where I found the sinus crossing the mastoid at a very high level, as if to connect the lateral sinus and jugular bulb by the short- est possible route ; there were more cells be- low and behind than above and in front of the sinus ; the antrum seemed especially deep in a small triangular cavity and was canted at a peculiar angle, and the nerve, though not uncovered, must have occupied a high level in the posterior canal wall to permit the sinus to go under it to the bulb. The vein, how- ever, was not thrombosed. Philip Kerrison has reported such a case. Familial sinus thrombosis probably has no place in otologic nomenclature. Yet, I had a case where throm- bosis of the sinus seemed to be a family dis- ease, for 2 older children had been operated on in another city for this complication, and while the mastoid in my case, the third in the family, was not especially suggestive of sinus involvement, the family history impelled me to explore, and the vein was found to be thickened and discolored but still patent. By the extra bone work, customary in such cases, I was able to avoid in this instance the sinus and jugular operation. The local bony find- ings did not emphasize extension by necrosis. Cheatle, as quoted by Oppenheimer, spoke of a vein connecting the middle ear and sinus. Its caliber was sufficient to admit passage of a No. 1 lachrymal probe. Could this have been a family anomaly responsible for the unusual frequency of sinus thrombosis? In forecasting the position of a sinus, whether unduly close to or away from the posterior canal wall, Whiting, it is recalled, stated that if the mastoid was round and convex, the sinus was probably close to the wall ; if a flat mastoid process, it was probably well back. Hetrick places some reliance on the posi- tion of the posterior perforated space as indicative of the downward turn of the under- lying lateral sinus. In spite of helpful sur- face markings, most of us by way of reassur- ance, seem to tip-toe in our operation until deeper landmarks are revealed. In closing the anatomic aspect of our sub- ject, it may be said that in acute otitis media the center of expansion would seem to be in the posterior superior region of the tympanic cavity, from which part cells diverge in al- most every possible direction. While com- munication with the mastoid antrum is easiest in the vast majority of cases, it is conceivable. 24 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 in freak formations, that free intercellular communication may tend in unusual direc- tions. Pressure is equal in all directions if we may apply here the Pascal principle. It is a matter of resistance to expansion. Cellular connections may take the process far afield of the original focus, and at a very early stage of invasion. A boy about 12 yr. old came to me with the story that swelling of the cheek occurred almost coincident with his ear-ache and ear discharge. While his ear canal and mastoid tenderness were not significant of severe mas- toid involvement, his temperature and face pain compelled action. Relief was immediate and lasting in spite of the fact that there was no unusual pathology in the zygoma. It is much in the same way that resolution occurs in Gradenigo syndrome cases after the simple mastoid operation. Trouble is relieved by retrogression in many cases if the operation is carried close to the supposed center of maximum pressure. Bowers, at a recent meeting of the New York Academy of Medi- cine, reported a case of extension in probably the same manner, because he was able to in- sinuate a fine probe in the path of the sinus that extended to the nasopharynx. A post- pharyngeal abscess was the ultimate thing in this case, as in one of my own, in a much younger patient however. The venous plexus connecting the middle ear and the orifice of the eustachian tube probably explains the pathway of infection in some instances (Op- penheimer). Max M. Kulvin reported a true case of subtemporal abscess, explaining that pus determined itself in the zygomatic fossa because the anterior fibers of the temporal muscle are loosely attached while the posterior ones are firmly adherent to the skull. Many years ago I saw a case that presented pus in the cheek. Trauma of the mastoid process that affects • the underlying cells to the extent of requiring operation is illustrated by a case I saw oper- ated on by Elliott Shipman, during my hos- pital internship. A young adult had been shot and the bullet flattened out on the mas- toid process near the tip. The destruction was extensive enough to justify the simple mas- toid operation. Imperatori recorded the case of a baby that developed an operative mas- toiditis from a fall, the impact being behind the ear; a sinus thrombosis complicating be- cause the sinus plate had been fractured. Many excellent articles, too numerous to recite, have appeared on the peculiar nature of the Streptococcus mucosus infection of the middle ear and mastoid. Guggenheim and Ferris recently contributed an illuminat- ing article on this type of infection, entitled “dry necrosis of the mastoid”, in consonance with the title chosen by Oscar Wilkinson. Cases are recorded by others where middle ear symptoms were lacking, suggesting the descriptive title of mastoiditis without tym- panic involvement. Also, under the title of “atypical mastoiditis”, the odd ways of the Streptococcus mucosus have been described. Guggenheim and Ferris introduced their cases as representing a peculiar form of mastoiditis characterized by an infection of long duration, few symptoms and an extensive dry necrosis. New, I think it was, found that these cases occur with an infrequency of 1 :500, and it lias not been my privilege to meet a case with positively no antecedent middle ear involve- ment. Some years ago a woman aged 30 came under notice with indifferent tympanic and mastoid symptoms, but a low grade headache on the suspected side, a slight fever and a hemorrhagic nephritis. Operation disclosed a mastoid that appeared to be undergoing reso- lution— not a drop of pus or other secretion was found — simply a little redness; yet, threatened chagrin faded as all symptoms promptly subsided. A 7 yr. old boy, answer- ing the same type as to symptoms, except renal irritation, showed the self-same condi- tion of the mastoid and the same satisfactory postoperative course. In another instance, in a girl of 20, the operative findings were totally different, yet the healing process, though rapid enough, was almost alarming in its dry- ness. No cultures were taken and it is un- fortunate that the organism was not isolated in any of the foregoing cases. Dry healing seems not to be mentioned in the reported cases of dry necrosis and may be quite an- other infection. Kopetsky thinks that the Jan , X&31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 25 Klebs-Loeffler bacillus may be the organism in some of these atypical cases. J. G. Dwyer, in a personal conversation, stated that the Streptococcus mucosus may give trouble even after the ear and wound have healed, the hypothesis being that trouble starts anew when the capsule of the organism is dissolved, possibly a matter of months longer; since the outlet for the new discharge has been shut off, intracranial complications threaten. With a dry ear, a normal canal wall, and all in all a dearth of local symptoms, the diag- nostic ability' of the clinician is surely put to the test. With regard to children an observ- ant mother may save the day. An ear his- tory, however remote, may provide the single clue. Altered appetite of the child, failure to gain in body weight, morning moisture of the night clothing, have, singly or in combination, prompted me to make an investigation of the mastoid where constitutional reasons seemed lacking. A night’s sleep that is disturbed, if only for a little while, may be tell-tale, as pointed out by Ewing Day, of Pittsburgh. Misbehavior of peristalsis has been alluded to very much in recent years and some of the members of this Section may wish to elabor- ate on this symptom. As regards adults, Mac- Kenzie says that most local symptoms may be absent, but least frequently of all, some drooping of the posterior canal wall. Many writers seem to concur in this opinion. With a dry middle ear, but a suspected mastoiditis, Hetrick thinks that the Weber-Schwabach paradox test is of assistance in arriving at a diagnosis. Again, easily induced fatigue may suggest the undertow of a long standing but latent infection. W. S. Tomlin reported a case of 10 yr. of invalidism and the prompt gain in weight of 20 lb. after a mastoidectomy. According to many, audition may be unaffect- ed, but should always be tested for possible loss. In these obscure cases it is the indi- vidual as much as the ear that might disclose etiology of the illness, bearing in mind that a systemic something may be found to act as a herring across the scent and delay the cor- rect diagnosis of mastoiditis. It is not the many symptoms in the early phase of the disease that should concern us, but the lone and persistent symptom that too often finds us complacent. As, between the meaning of white cell and red cell count, each has its adherents. Latent mastoiditis, in Hetrick’s analysis of reports, occurs anywhere between babyhood and senescence. The period of latency may ex- tend. as in Bar's case, up to 2 years, perhaps more. As already quoted from Macuen Smith, serious pathology is not a surprise. The radiograph seems to serve its best use in • symptomless mastoiditis. Granger, in a re- cent contribution to radiology, described a technic and interpretation that proved useful with infants. It would be superfluous to report some of mv own experiences when the literature abounds in illustrative cases. The lack of tympanic symptoms in these odd cases of mastoiditis gives rise to the conjecture as to whether or not they may be of hematogenous origin. Glogau believes that primary mas- toiditis is a clinical entity. Taylor, of Jack- sonville, as quoted by Mallison, cites a case of mastoiditis developing secondarily to a bacteriemia, while T. E. Carmody, in connec- tion with Hempstead’s paper, recalled that a blood-borne mastoiditis seemed to occur in an ear opposite to the one he had operated upon. Classified as atypical and sometimes leading to operation is the type of case described as mastoidalgia. My Chief of Clinic was im- plored by a neurologist to operate on such a case. In his final letter of refusal he ex- plained that the best result he could possibly get would be to restore the ear to the condi- 1 tion it was then in. Byrd, in the course of conversation, cited a case where there was, however, a high degree of deafness, actual pain and occasional watery discharge, and on operating he found hyperostosis in the region of the attic and aditus, cramping the ossicles. After creating room where needed the pa- tient regained her hearing and enjoyed com- plete comfort. Harris related an instance where simply a skin incision yielded a splendid psychic result. If the maxillary antrum has now its back against the wall as to normality, the mastoid antrum, likewise, is seldom a nor- mal part in the eyes of critical observers. 26 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 i ime and again a radiograph of an unsuspect- ed mastoid antrum yields evidence of trouble. When is this antrum well, is a pertinent ques- tion. In viewing our middle ears and mastoids irom another angle, it almost appears that these parts are susceptible to vasomotor changes. A young man called at the office on different occasions with an acutely in- flamed middle ear and apparently a mastoid • inflammation. His attacks, while of sudden on- set, generally disappeared just as suddenly in a few hours, suggesting an analogy with the mucous membrane of the nose and maxillary antrum that balloons and then collapses with rapidity. Ilaskin, with others, believes that an abscessed tooth, even without sinus in- volvement, may alter the course of a mastoid inflammation. Two cases have come under my care where extractions seemed to cause an abrupt turn of events for the better. Robert H. Fowler believes that there are carriers of mastoid disease, and I hope he will explain, while here, his scientific example of cherchez la femme. Meanwhile, it is hoped that these scattered remarks on the mastoid and some of its peculiarities may lead you to tell of bigger things. Discussion Dr. Henry C. Barkhorn (Newark) : It is always a pleasure to discuss a paper of Dr. Pannell’s. He has a message, and he gets it across. Atypical mastoids are the bane of our lives. It develops that the more mastoids you see, the more mastoids you do, the fewer are typical if you get back to your fundamentals. In the infant, the antrum is at 12 o’clock; at 1 year it is at 1 o’clock; at 3 years it is at 3 o’clock. Naturally, the child has prolapse of the canal without mas- toiditis because the antrum is right over the canal. When a child has a funnel-shaped canal it has a mastoid; these are the cases that don’t get well without operation. Of children who have a pro- lapse of the canal, the vast majority get well on conservative treatment. If you follow along anatomic instead of pathologic lines in your operative procedure, you will make fewer mistakes. Take out all the cells that may be diseased, not only the cells that are visibly dis- eased. Consider the ear that is apparently normal but has a history of earache, that has half-headache, has pain behind the eye; this brings us to the work that Dr. Eagleton has recently done, and, by the way, there is an article in the March Archives of Surgery — not of Otology but of Sur- gery— by Dr. Eagleton that is of outstanding im- portance. There are 2 ways that you can get an apex involvement. One is through the extensive cellularization of the petrous pyramid. The other is bv an embolic process. The one is sick from the very beginning, has a headache out of proportion to his mastoid findings, may or may not have Gradenigo’s syndrome, but he gets well in the vast majority of cases without any further operative procedure because his is the cellular mastoid. The other patient has a mastoid, is doing moderately well, and suddenly has a shot of temperature, chill, rigor, convulsion if a child, and then has a pain behind the eye, middle and posterior fossa syndromes; he has something in the apex of his pyramid which doesn’t get well. No matter how extensive your mastoidectomy is, you can’t drain an osteomyelitis, embolic in nature, in the bone marrow of the apex. There is where Dr. Eagle- ton’s operation, of unlocking the deepest portion of the petrous pyramid, comes into its best field. He takes away the dural plate, takes away the sinus plate, takes away the angle of the petrosa, unlocking the posterior and the middle fossa, he separates the dura in as far as the apex in the middle fossa, separates the dura in as far as the internal auditory meatus in the posterior fossa, and if there is anything there finds it. That is the real reason for such success as we have had, this operation of unlocking the petrous pj ramid. Dr. Robert H. Fowler (New York): Dr. Pannell and I worked together in Dr. Rae’s ear clinic at Manhattan, and in talking over his paper I told him the following story about a child 4-5 years old who had a mysterious mastoid infection which repeated operations failed to clear up. Talking about affinities — the child’s family was French, the child could not talk English, and they had a French nurse who must always be present. It was not possible for the surgeon to handle the case and still get rid of the French nurse, so she was always present with that child. The French woman and the child were so passionately fond of one another that it was pathetic to see when Madamoiselle had to take an occasional hour away from the bed side. The trained nurses who had the professional responsibility kept objecting to the presence of someone who would disturb the diet and who brought in irregularities and innovations. The operation had to be repeated more than once, and the best consultants in town had no sugges- tion as to why this child should be singled out more than others for recurrent infections, until one day Madamoiselle herself came into the office with a running ear, developed an acute mastoid and then for the first time acknowledged that she had been suffering for weeks with earache. As soon as she was definitely off the case the child’s mastoid cleared up. The professional nurses thought that Madamoiselle had been kissing the child, contrary to orders, and that she was a carrier. Instead of. a “Typhoid Mary” this was a case of “Mastoid Madamoiselle”. There was a curious sequel to that story; 3 months after the nurse recovered from her own mastoid operation the question came up as to whether I would be willing to recommend her to another family as a child's nurse. T liked this Madamoiselle. She had been very loyal, she had every virtue that a human being can have, and had showed a remark- able affection for the children. But 2 of the chil- dren in the first family had endured mastoid operations, and though she was a good children’s nurse it was a matter of professional judgment as to whether there was not a risk of her carrying infection into a new family. There was so much doubt about this that I found it better not to recom- mend her. She didn’t get the job but went to work somewhere else, and now you will be surprised when I tell you that the child that she did not take Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 27 care of came down with an acute mastoid. So, perhaps it was just as well for the French nurse that she had not taken that job and incurred any question of blame. This story if it stood alone would mean nothing, but it does not stand alone. Perhaps you will re- member that Oliver Wendell Holmes was a doc- tor, and that he discovered by making observa- tions in ward work that puerperal infections, post- partum infections were contagious. That was 60 years ago, and we now take full precautions against the spread of such infections, but are we justified in assuming that otitis and mastoid in- fections are never contagious? I think not, for in my own practice there have been not less than half a dozen cases where a patient seemed to get the mastoid infection from someone near by who themselves suffered from acute or chronic ear trouble. In a ward of 40 mastoid cases in the army 2 things happened that would be surprising if it were not admitted that certain germs have definite affinities. It isn’t on the cards, it isn’t in the books, but the orderly whose job it was to pick up the cotton in that ward came down himself with an acute mastoid, and two weeks later 1 of the doctors, a general medical man who had his quarters directly across the hall from my own, came down with an acute mastoiditis and had to be operated on. From then on, screens were placed between the beds in the ward and other steps taken as though the streptococcus was con- tagious. This thing doesn’t happen often, but when you have recurrent mastoids to handle let me advise you to look with suspicion at those who are in closest contact with your patient, remembering my story- — cherchez la femme! Chairman Emerson : This subject that Dr. Fowler speaks of is new to me, but it certainly is something more than coincidence. Last Monday night, I asked my associate to do a mastoid oper- ation on a dentist’s son. This dentist has 2 boys. His other boy has had 2 mastoids, and this was the second this boy has had. They are the only children in the family. Incidentally my 2 daugh- ters had mastoiditis and were operated on 4 days apart, several years ago, during an epidemic of measles. We have often remarked in our work that it was remarkable that there seemed to be certain families with 1 to 6 children, in which we have done in the last 10 years anywhere from 3 to 8 mastoid operations. There are some families in which all their children, 3 or 4 children, have had mastoiditis. I have in mind 1 girl, a very strong, healthy, well-developed, handsome girl, of 12 who had 7 mastoid operations; 4 were done by sur- geons in New York before I saw her, and 3 were done by me in 3 successive years. This child had an excellent nose and throat,, yet every time she got a cold, one or the other of her mastoids blew up. What Dr. Fowler has said certainly gives us food for thought. It does mean, as I look back over our practice of the last 20 years and recall the numerous families in which we have had multiple mastoid operations, running as high as 8 in some families, that it merits serious con- sideration. People have said to me: “Is mastoid disease catching, or can this child which has had mas- toiditis once have it again, or is it more liable to have it than one who has never had it?” My answer has nearly always been to all those ques- tion, “No”, but I believe that I have been mis- taken, and I believe there is a certain kernel of truth in what Dr. Fowler has had to say on this subject. TONSILLECTOMY UNDER LOCAL ANESTHESIA* Robert H. Fowler, M.D., New York City The modern tonsil operation under local anesthesia is a far, far better thing than those that preceded it. Bleeding is controlled; there is no pain, and only slight discomfort ; the operation is an open one with full visi- bility at every step, and it is complete, remov- ing tonsil and infratonsillar nodules to the very base of the tongue; and, in the most successful cases the slight trauma leaves the muscles of the tonsil bed intact. To obtain these desirable results it is neces- sary to pay attention to the details of technic. Not any particular man’s technic nor any one set of instruments. The improvements I am about to speak of have been instituted by many surgeons in different parts of the coun- try. It will simplify matters to take them up under the following 14 points : .( 1 ) Spraying the throat with parasthesin powder. (2) Injection of novocain; floating the tonsil. (3) Incision. (4) Grasping the capsule. (5) Cleaning the white layer of the cap- sule. (6) Fibrous attachments freed. (7) Mucous glands saved. (8) Upper lobe cleared. (9) Differentiating and injecting mus- cular belt. (10) Sponge placed in fossa. (11) Shaving off muscles. (12) Snaring lower pole. (13) Removal infratonsillar nodules. *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Section of Oph- thalmology and Rhinolaryngology, Atlantic City, June 13, 1930.) 2 S JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 ( 14) Powder fossa. Tie vessels. Examine removed tonsils. The time is short arid it is better to illus- trate with pictures and speak briefly than to read any lengthy discussion. (The technic hereafter described was illustrated by lantern slides.) Parasthesin powder full strength is sprayed on the throat twice with a 2 minute interval. The surface of 'the tonsil and pillars, and per- haps the whole pharynx, is included if there is a persistent reflex. Then 10% solution of novocain on an applicator wound tightly with cotton is rubbed over the surface of the pil- lars and plica triangularis. This is done 3 times at 3 minute intervals, the applicator being turned or spun in the fingers each time. Ten minutes later an angular needle is used to make injections of 1% novocain with a few drops oi adrenalin added. The object is to float the tonsil, introducing the needle pre- cisely where the incision is to be made. The point of the needle must always be placed close to the capsule in the theoretic space be- tween it and the surrounding muscles of the tonsil so that the solution cannot be absorbed but will come out at once when the tonsil is removed. The fluid starts to run out the moment the incision is made. The initial prick of the needle can be made barely per- ceptible, if the point is sharp and the needle fine, arid the novocain is projected *4 in- al- ways in advance from there on. It is not sufficient to flood the upper lobe, that is the upper pole, of the tonsil, but even greater care must be exercised in flooding the lower lobe; and this is, for anatomic reasons, a more diffi- cult procedure. Posterior pillar flap. It is difficult to run the incision straight down the posterior pillar without tearing the mucous membrane. It can be accomplished better with a sharp knife and it is often found possible to shape a flap to cover in with mucous membrane the upper quarter of the posterior pillar. Fixation of posterior pillar is helpful. Anterior pillar. The incision is carried dowward over the plica triangularis, saving a flap of mucous membrane from its surface, and terminates at junction of the anterior pil- lar with the base of the tongue. If the whole of the mucous membrane from the plica tri- angularis be left in the throat it is often found to contain lymphoid tissue, infratonsillar nodules, at the lower third. These can be seen and the incision can be patterned to skirt them before reaching the base of the tongue. Grasping the capsule with forceps is an im- provement that has lately been introduced. It has an advantage over the established custom of seizing the lymphoid mass of the tonsil tissue, in that it keeps the capsule taut and gives a higher degree of visibility. The for- ceps used for this purpose is an Aliys clamp with box lock and extra grasping teeth. The white layer of the capsule is the final single layer of pharyngeal fascia on the north pole of the tonsil. The more professional certi- tude displayed in denuding this thin layer, known as the capsule of the tonsil, without breaking it, the better chance there is of es- caping hemorrhage and leaving a protected wound ; one with enough fascia covering the muscle's to prevent their becoming infected. The fibrous attachments are cleared from the upper pole by meticulous sharp dissection and the mucous glands with their blood supply are separated from the tonsil. The lilliputian attachments are shaved from the tonsil bit by bit till the pink layer to be left in the fossa is clearly contrasted with the white dry sur- face of the upper lobe of the tonsil. When the upper lobe has been altogether freed the muscular attachments appear attached to the equator. It is well to inject these with novo- cain to cut off a branch from the ninth nerve. A sponge, half the size of your thumb, is placed above the tonsil at this time and the upper lobe of the second tonsil is freed. When the sponge is removed the muscular attach- ments at the belt and lower lobe can be shaved from the surface of the tonsil with a razor edged knife. By shaving I mean a process of freeing bit by bit the firm attachments be- tween the capsule and the tonsillopharyngeus muscle. There is an old saying — “beware the snare-'. That phrase, when I use it, means use your snare not to dissect muscles but to sever the lower pole from the base of the Jan.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 29 tongue and to clear away irifratonsillar nodules, if any are present, from the lowest portion of the plica triangularis where it at- taches to the base of the tongue. These nodules have come in for a great deal of dis- cussion lately. When left in the throat they prevent the clearing up of cervical adenitis. When the tonsil with the infratonsillar nodules has been removed, the operation may be finished by powdering the fossa with bismuth and tying 1 or 2 of the larger vessels. The most important one is at the center of the fossa where the posterior pillar joins the lateral wall. Instead of a slip knot, a needle may he used to place a suture under these vessels. ADVANTAGES OF GENERAL ANES- THESIA IN TONSILLECTOMY* William Campbell, M.D., East Orange, New Jersey Although I am speaking on the advantages of general anesthesia, I do local anesthetiza- tion on suitable cases. Looking over my rec- ords of patients over 16 years of age, I found that 65% were done under general anesthesia, but I do not mean to infer that a greater per- centage could not have been done under local hut that general was the anesthesia of choice in those cases. In neurotic people where apprehension is apt to be present, there is considerable .mental shock during local anesthesia. In one case I know of, a highly strung woman was in bed for several months following a nervous break- down that occurred a week or two after the operation. Where bleeding may be expected, or where you have an excessive amount of fibrous tissue, from repeated peritonsillar ab- scesses, I feel that general anesthesia is easier on the patient and certainly much easier for the operator ; and I do not know of anything more trying than a tonsillectomy under local anesthesia on a panipky patient. *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Section on Oph- thalmology and Otorhinolaryngology, Atlantic City, June 13, 1930.) In arteriosclerosis and high blood pressure the use of adrenalin and novocain will some- times raise the pressure 20 points. In such types I decide by judging the individual and have not had any trying experiences either way. A few months ago I had a 9 year old girl, referred to me by an internist, with the history of a congenital pulmonary stenosis and a rheumatic condition. He did not con- sider the heart competent for general anes- thesia, and considered the case a poor risk. The urine was normal, also the bleeding and clotting time. I removed the tonsils under local anesthesia and with very good co- operation from the child. She had an ex- cessive amount of adenoid tissue, which was removed under first stage ether anesthesia. The child did not have any postoperative- bleeding from the tonsils, but 10 hr. later had a uterine hemorrhage of 500 c.c. which was repeated twice, making 1500 c.c. in all, and did not stop until after a small transfusion. After the hemorrhage, cyanosis was gone and the child never was in shock. A blood count taken later showed 6,500,000 red cells without any abnormal findings. I do not know to what we should attribute the cause of the hemorrhage. In children, I prefer general anesthesia. I have seen, several times, uvulectomy and in- jury to the soft palate result from intract- ability of the patient under local anesthesia. Adhesions of the pharynx need only be under one’s care for relief to make us sufficiently appreciate the necessity of prevention. A competent anesthetist and assistant are essential, and I have not had any complica- tions, such as lung abscess, etc. Hemor- rhage, under general anesthesia, will be greater at the time of operation but you are in a bet- ter position to control it and in all cases the throat should lie dry before the patient leaves the table. I believe you are more liable to get postoperative bleeding 5 or 6 hours later after local than after general anesthesia. I do not see any reason why the actual me- chanical work, using the dissection and snare method, should not leave just as good an after-result whether it be . done under local or general anesthesia. I think the outstanding advantage of gen- 30 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 eral anesthesia is the convenience to the oper- ator. Discussion Dr. Theodore W. Corwin (Newark): I think we have listened to a wonderful description of the tonsil and tonsil operation, by Dr. Fowler. I am sorry that our discussion must be limited at all. One hates to be limited when he has such an op- portunity for speaking of this wonderful subject. The demonstrations by Dr. Fowler really very much simplify the subject. You know from your own observation and experience that the relation of the tonsil to the outer wall of the throat is comparatively little understood. In fact, so far as we have had to depend on text-books for the anatomy of the throat, very little has been said of the external relations of the tonsil, and yet they are what we are up against. It is to be remem- bered that the operation of tonsillectomy is really an operation that is extratonsillar in character. We don’t operate on the tonsil. It is very important, therefore, that we should know the external re- lations of the tonsil. I have tried to keep up with the methods of doing the operation. My preference has always been for the dissection and snare method, using the snare method a little more freely than we used to do or than Dr. Fowler suggests. As compared with other methods, I think the dissection snare method has very great advantages. The ad- vantage Dr. Fowler speaks of is notable, in that you can follow the course of the operation very carefully. The great point, of course, that Dr. Fowler has demonstrated, is the existence of mus- cular tissue which enters from the muscles of the throat wall into this fibrous capsule or into that layer of pharyngeal fascia which coinstitutes a capsule for the tonsil. I know very well that we encounter difficulty in clearing the tonsil cap- sule at the equator of the organ, but the ex- planation before has not been very explicit. Now. we can go out with an understanding that will aid us greatly and save us very many compli- cations. The question of hemorrhage always comes up. I don’t want to enlarge upon that except to say that entry of the blood vessels into the tonsil occurs through this equatorial region which con- tains muscle fibers. In approaching the tonsils, the arterial vessels keep subdividing and attain small caliber perhaps When right in contact with the tonsillar tissue of the capsule. If you cut through the muscular attachment, you encounter large vessels, comparatively, and you are more liable to have bleeding. If you are careful to fol- low the actual surface of the tonsil, as near as can be, you cut across these vessels when they are down to a comparatively small size, owijng to rapid subdivision. The subject of anesthesia has been demonstrat- ed beautifully by Dr. Fowler. I notice that he makes more insertions of novocain solution than I have been accustomed to, and notably the direct in- jection to the glossopharyngeal nerve opposite the lower lobe of the tonsil. That is an important point to be remembered as even at best under local anesthesia there are some people who feel a little pain when the glossopharyngeal nerve is approached. I have always been accustomed to giving my patients morphin and hyoscin in such doses as to make them stuporous an hour before the operation, and generally patients have no pain if they attain that condition. The pain is more apt to develop when the snares are used. That is a violent process and not only cuts but it also draws upon the tissues of the throat all around at some distance from the cutting wire. 1 will say that local anesthesia can be made very complete in- deed. I do it for nearly all my operations where the patient is able to sit up and control himself. 1 think the main part of control is psychic. If the operator is nervous and fidgety he doesn't have team-work, and if he shows any apprehension or awkwardness himself that is sure to be imparted to the patient. But if an operator approaches with confidence, the patient will be assured. Things to be avoided are those which excite the patient. I think that depression of the tongue is one of the things you have got to be careful of. I depress it very little and turn it to one side. If you bring the tongue in contact with the posterior wall of the throat you are sure to have some difficulty of breathing, and that is a thing which is bound to excite the patient, in the same way, the posterior wall of the throat must not be touched by the in- strument. Never swab the posterior wall of the throat if you want to get along comfortably. Dr. IT. V. Hubbard (Plainfield) : I have been rather surprised that there has been no mention of the toxicology of local anesthesia. Since novo- cain has come into use there hasn’t been much question about the toxic effect, although there have been some cases of mistake in solution used, and in my experience at the Post-Graudate Hos- pital in New Y'ork I have seen some instances of toxic effect. The method of operation may vary with the operator. One man gets accustomed to using a certain form of modified Sluder, and does it very well, producing good results; and another man gets accustomed to the dissection and snare, and he also does the operation very well. So that in the hands of different men different operations and good results may be obtained. Dr. Dikran M. Yazujian (Trenton) : In the mat- ter of anesthesia I think we should be careful in lubcrculous cases. I remember seeing at least . 2 such patients who had their tonsils removed un- der general anesthesia which aggravated their dis- ease and death followed in a short time. I think it is a great mistake to operate, on people with tuberculosis under general anesthesia. We must draw the line there, I believe: We must always operate on them with local anesthesia, and I pre- fer. like Dr. Fowler and others, novocain with adrenalin in it. Injecting the tonsil, I find that only 3 points along the anterior pillar are all we need, because, the fewer points we inject the less edema we will get and the less obscuring of outlines of the pos- terior pillars. I go through the anterior pillar and inject behind the tonsil in 3 places. The lower pole of the tonsil we must thoroughly anesthetize because in my experience it is the most sensitive part. There is where the patient will have pain if it is not anesthetized well. The kind of tonsil syringe is a very small mat- ter, but I experimented with several different kinds and the one I found most satisfactory was the Cook syringe. It is nothing but the frame of a syringe, as you know, and the novocain carpules come all ready to be slipped in to take the place of the barrel. Yrou just take out the used carpule and slip another one in and it is ready again. Another advantage of it is that there is no danger of get- ting your solutions mixed. For instance, if you have been using cocain for surface anesthesia be- fore you inject the tonsil, there have been cases where cocain and novocain have been confused Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 31 and the patient has died from the injection of cocain. This method avoids all that, because the carpule comes with the right solution in it and labeled. I think we all agree that patients who have had attacks of quinsy should be given general anes- thesia instead of local, because there is so much scar tissue that the local anesthetic will not pene- trate enough to make the operation painless. As to the technic of tonsillectomy, after using dissection, snare and Sluder methods, each for sev- eral years. I have adopted the La Force technic, which I have now used for 6-7 years. I prefer it to the other methods because it removes the ton- sils, and only the tonsils, cleanly and with much less bleeding and with much less reaction in the throat. Dr. Fowler (closing) : It has been a great honor to come down here and talk to you and show these movies to your society. I like to meet men who are on the frontier of our work, who are themselves doing the operating day by day and who are willing to listen to something which may help them. There is no subject that is numerically so important as the tonsil operation; it constituted one-third of all surgery in the United States dur- ing the last 10 years, and there is no operation we owe more to in the way of study. The suggestions that were made in the discus- sion can be very quickly answered. I have here something which I think covers 2 at 1 shot. This is an x-ray film of the lungs of a child 5 % yr. old whose operation had to be done under local because, as you will see, the tuberculous process had destroyed one lung. The doctor who sent the child into us said that to give ether was out of the question, the tonsils were very bad and the oper- ation under local would be. a life saver if it could be done. The operation was successfully per- formed, thanks to using the kind of psychology that Dr. Corwin has suggested. The boy was given a promise of a boat as a present from his mother if the first tonsil came out all right. A tear trickled down his cheek, then he was told that he could have his choice of another present if he let the other tonsil come out, and he sent out word to his mother, after thinking a minute that he would like a radio on the boat. The mother said he could have that, and then gently and slowly the novocain was introduced. I don’t know whe- ther you have ever seen an operation on a child well under 10 yr. old of that type, but it was re- markable with what ease physical removal of the tonsil took place, and it is remarkable sometimes to see how these children react to the proper en- couragement, undergoing what used to be thought a, very difficult procedure. Dr. Hubbard, I think it was, spoke of the toxi- cology. I apologize to you for not having taken that matter up. It is, I think, the one serious danger to be thought of and must be considered by everyone doing local work. Everyone who has done any of this work has seen either fatalities from that or dangers of fatalities through the accidental substitution of a drug, because the 2 clear fluids are on the table in similar glasses, and the doctor, thinking of his work, gets the syringe in the wrong glass. This can be definitely pre- vented by coloring the stronger solution. Chairman Emerson: How about adrenalin'; Dr. Fowler: Adrenalin I think is very much less apt to cause fatalities, because the adrenalin is added by the nurse, say, the 6 drops or whatever you order beforehand, to the solution, and the doc- tor isn’t apt to put his syringe into a brown bottle marked adrenalin. But he is apt to take a strong solution (10% cocain) that is clear white and is on the table there next to a weak solution (1% novocain) that is clear white and also on the table. These may get mixed at the pharmacy, they may be mistaken by the nurse, they may be substituted by the doctor. You have got to prevent in your local work absolutely any such thing as that happening or you will have accidents. I have seen in New Y’ork 2 actual fatalities in the hands of doctors of high repute through their making that mistake, and it is easy to prevent. You just put a fence around it, if you know what it is. One of the doctors suggested that a Cook syringe is the answer. Well, that is one answer, a syringe with an ampule, where the solution is made up beforehand. Or, if you prefer to have another syringe with perhaps a finer needle than the Cook— it has a rather heavy needle — you can use the solution fresh from the ampule put into an open glass at the time. There is another way, and that is if you have novocain 10% on your table, or perhaps you choose to have 10% cocain there, then have it a different color and you won’t mix them. I always have my strong solutions on the table blue or red and so well marked there is no danger. It is known nowadays that there is no danger in adding a couple of drops of gentian violet, and that pre- vents you from substituting the stronger solution for the weaker injection fluid. That certainly should have been mentioned in this paper. A STUDY OF OBSTETRIC MORTALITY J. C. Hartman, M.D., Germantown, Pa. As an introduction let me state that some people say obstetrics has become a surgical specialty. To this we cannot subscribe, for the majorit)^ of all deliveries always have been and always will be conducted by the general practitioner. The advance that has been im- parted to surgery through the perfection of technic, bacteriologic studies and practice of asepsis, has placed at our disposal a means of opening the birth canal that was not dreamed of heretofore. That this weapon has been used with indiscretion is only too apparent. Let us for the moment glance at some inter- esting statistics, concerning the maternal and infant mortality and morbidity. First is a report of the New Orleans Gynecologic and Obstetric Society, which covers the cesarean sections performed in 6 hospitals of that city over a period of 6 years. 32 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 During- the years covered by this report. 291 cesarean sections were performed and the in- cidence based on 16,000 deliveries in the same period was about 2%. More than j/j of those operations were done by 3 men, 1 an obste- trician and 2 general surgeons. Only 12% were done by the transperitoneal low cervical technic. An analysis of the maternal mortality from the standpoint of indications for opera- tion shows that out of 41 eclamptics in the series 17 were lost, a mortality of 41.5%. The operation for other toxemic conditions gave a mortality of 25%. Glancing at the fetal mortality, one is impressed first by the fact that out of 55 deaths, 20 occurred in prema- ture children. Immediately the question arises whether cesarean section is justified for pre- mature babies. As a direct result of placenta p'rbvia 13 children were lost, which is more than 39%. In this series of 291 cases, 47 mothers were lost, a mortality of 16.1%; 55 babies, a mortality of 18.9% ; and the fatality was a dual one in 16 cases. Since the above report, 31 cases were operated upon by the low cervical technic with no mortalities. Now let us look at a survey of cesarean sec- tions in the Borough of Brooklyn during the same years. In this group there were 934 cases with a maternal mortality of 54, or 5.8%. In 104 cases that were operated on for eclampsia there were 27 deaths, a mor- tality of 26%. A fetal mortality of 25.6%. Among 273 classical operations in which no vaginal operations had been made there were 16 deaths, a mortality of 5.9%. Among 199 classical operations where vaginal examina- tions had been made there were 27 deaths, a mortality of 13.6%, Among 66 lower seg- ment operations without vaginal operations there was 1 death, a mortality of 1.5%, and among 57 of these operations performed after vaginal examinations there were 6 deaths, a mortality of 10.5%. The latest report comes from the city of Los Angeles, over the years 1923 to 1928 in- clusive, with a series of 1322 sections, 1060 classic and 262 low cervical, performed in 12 hospitals, with a mortality of 4.2%. In the series of 1322 cases there were 107 fetal deaths, or a mortality of 7.9% ; 37 of these deaths were in premature infants, 6 were monsters and 5 were still-births. This is a much better report, but leaves much to be desired. I wish to give you the indications for this group of 1322 sections: Pelvic disproportion . . 488 Eclampsia 46 Premature separation .... 25 Previous abdominal operations 30 No progress ... 112 Cardiac disease „• 38 History of difficulties 29 No cause found 42 Prolapsed cord . . 4 Prolapsed cervix 1 Fetal distress 2 ■ Contraction ring 3 Ruptured uterus 4 Intrapartum infection 1 Intestinal obstruction 1 Recent laparotomy 1 Strangulated hemorrhoids . . 1 Hydrocephalic baby 1 Previous cesarean 197 Preeclampsia 187 Placenta previa 68 Fetal malposition . . 61 Old primiparas . 55 Fibroids 28 Sterilization 27 Insanity 1 Epilepsy 1 Anemia 2 Pernicious anemia 1 Request 4 Thyroid . . . . 1 Diabetes 1 Pyelitis 2 Gain in weight 1 Nervousness 2 Doubled uterus P Dysmenorrhea 1 Dead fetus 2 Now let us look at the mortality records of the United States in the past 10 years. In 1915, the maternal mortality rate in the reg- istered area was 6.1%. In 1920 it was 8%; in 1927 it was 6.7% per thousand births, and of this number 40% of all maternal deaths were due to infection, supposedly a preventable cause, while 27% are chargeable to eclampsia and the toxemias. Of the remaining 33% about 10% may be allotted to dystocia and operative labor. The remainder may be credited to the accidents of pregnancy and labor. To substantiate the belief that operative inter- vention increases maternal mortality, listen to the mortality rate in Massachusetts. In 1901 the rate of deaths per thousand live births was 3.8% ; in 1905 it was 4.2% ; in 1910 — 4.8% ; in 1915—5%; in 1918—8%; in 1920—7.5%; in Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 33 l°24 — 6%. In an analysis of 1000 fatalities, death occurred in 225 from puerperal infec- tion, 217 from toxemia, 140 died from acute infections, 129 from hemorrhage, 97 died of embolism, and 49.5% died of heart disease. Therefore, septicemia, toxemia and hemor- rhage— causes which are preventable — were re- sponsible for 58% of the deaths. In 58% of the cases operative procedures had been re- sorted to. With the above statistics before us, that speak for themselves, let us seek for measures to brighten the situation: (1) Better funda- mental obstetric teaching in our universities. (2) More careful supervision of our residents, Leaching them how to observe the normal. How many instances do you see where the resident physician is only called just in time to put on his gloves and tie the cord. He, in his youth and enthusiasm, feels that to get anything out of his hospital training he must do forceps, version, episiotomies and all the operative procedures connected with the ser- vice. Unfortunately, in many institutions he is aided and abetted in his desire by careless- ness of his superiors, either on the staff of the hospital, who are not doing special obstetric work, or by the courtesy staff if it happens to be an open hospital. He should be taught, first, the dangers of operative interference and made to observe the normal physiologic me- chanism of labor, so as to appreciate when the normal is at fault, and to expect help when this mechanism is abnormal. The more he is made to appreciate the dangers of operative interference the better will be our maternal mortality, when he joins our midst as a prac- titioner. Prenatal care. Here I wish to consider principally eclampsia and preeclampsia. From the foregoing statistics I am sure you are all convinced that cesarean section has no place whatsoever in the treatment of eclampsia. In most of these cases the child is dead from the toxemia or is premature and death occurs soon afterward. These cases are treated with greater safety to mother and child by early hospitalization, complete rest, dietetic and -eliminative measures with induction of labor in the preeclamptic stages. If eclamptic, the recognized procedures, such as morphin in massive doses, elimination by bowel and stomach, glucose, magnesium sulphate, and as normal a delivery as possible. Since 27% of our maternal mortality is charged to toxemia we would do well to increase our carefulness in prenatal care. Insist on the patient follow- ing directions as to diet, amount of water in- gested, keeping the avenues of elimination open and strict attendance at your office as often as necessary to check the blood pressure and urinalysis. In your prenatal study be careful to eliminate all possible sources of focal infection. Remember we do not know the cause of eclampsia, and that all our ef- forts must be toward elimination and lighten- ing the burden of the kidney and liver. In hospitals with well regulated out-patient departments eclampsia is almost entirely eradi- cated ; it is rare to see such a case but the in- cidence is just as great as ever. Therefore, this 27% of our mortality must be placed at the door of careless prenatal care and un- sound surgical judgment. Unnecessary cesarean section. As you listened to the indication for cesarean section in the Los Angeles statistics, did it not sound like a High School farce ; picking out some of the high lights — fetal malpositions, old primi- paras, sterilization, request, pyelitis, nervous- ness, dysmenorrhea, dead fetus, history of difficulties, no cause, no progress, cardiac dis- ease, etc.? I am sure that out of 1322 sections more than one-half of them were not justified. When you realize that clinical experience has taught us that 60 to 80% of the labors in relatively, contracted pelves terminate spon- taneously, you can lop off in a stroke 288 of the 488 done for contracted pelvis. Eliminate 233 done for eclampsia and preeclampsia, and about 400 for foolish causes, and the ever present desire to operate, and you will agree that my estimate of one-half is low. With reference to complicating disease in pregnancy, the pregnancy in most instances can be disregarded and attention given to the treatment of the disease. Here again let me reiterate that cesarean section has no place in the treatment of eclampsia. Cesarean section in the treatment of pla- 34 JOURNAL OF THK MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 centa previa has a definite place. In central placenta previa it is indicated in all cases, primipara and multipara. In the marginal and lateral types the method of treatment is one of choice, especially in the multipara where we expect less difficulty in opening the birth canal. The condition of the cervix always guides our choice, if it is a long, hard snout- like affair and the baby alive, cesarean may show the best judgment. The condition of your patient is not the guide for your proced- ure. If she is in shock, treat her for that by intravenous injection of salt solution, glu- cose acacia or blood transfusion, before any operative procedure is undertaken. Simple rupture of the membranes with the jamming of the presenting part into the cervix is often sufficient to control the hemorrhage and labor terminates spontaneously. Statistics show that where cesarean is done in routine for all previas, fetal mortality is markedly raised, as so many of these infants are anemic from loss of blood and unless immediately transfused die within a few hours, whereas you have subjected the mother to more serious danger, from infection, especially if she has been ex- amined vaginally or, as often is the case, has been packed with any and everything in the emergency. All cases of placenta previa should be hospitalized as soon as the diagnosis is verified, so as to treat the woman asepti- callv and guard against loss of blood, which in turn lowers resistance and favors develop- ment of infection. Malpositions. The incidence of cesarean section is steadily increasing for this compli- cation and is very unjustifiable. It is done for occiput posterior, breech, brow, face, trans- verse and every possible presentation. This incidence is due in great measure to the gen- eral surgeon, called in consultation, not being trained in obstetrics, who does the thing that he can do best — a surgical operation, ces- arean section. In these cases it is better to consult the obstetrician who is trained in the mechanism of labor and who realizes that malposition is only one chapter in the patient’s obstetric career. Cesarean section relieves the present situation but places the mother’s life in jeopardy for all future pregnancies, as she has a 14% chance of the scar rupturing. I am not blaming the surgeons, as he extricated himself with the best weapon at his disposal, but if fear of the patient being removed from possible hospital care or receiving inadequate medical attention was present in our conscience we would seek another way out, because a cesarean predicates future demands for the highest type of attention and skill. Here again the finger of accusation points to lack of pre- natal care, for in a good prenatal clinic with examinations and palpation 2 or 3 weeks prior to delivery, you will detect the abnormalities when correction can be made, or if not cor- rected you know what you have to deal with and are prepared to carefully guide. labor from the onset. Elderly primiparas. The dangers and diffi- culties of labor in elderly primiparas have been greatly exaggerated, for statistics show that neither fetal nor maternal mortality is increas- ed above levels generally accepted as normal and the average duration of labor is only slightly prolonged, while 20% of the women have strikingly rapid and easy labors. Dys- tocia may be expected in about 15% of cases, and in most instances it is not a true dystocia but a weak uterine contraction that fails to dilate the cervix. These cases are helped tremendously by Gwathmey analgesia where the painful inefficient contractions are relieved long enough to allow the real expulsive second stage pains to begin. Development of the low cervical cesarean should lower this cesarean incidence by allow- ing patients to have a test of labor. If this is practiced most of these cases will deliver spontaneously. Many think that a test of labor is just so many hours. My idea carries with it, the condition of the patient, frequency and duration of the pains, their impression on the cervix, and whether they are of the ex- pulsive or the hugging type. No definite length of time, 4 to 18 hours, but a careful personal observance of the patient during the test period, controlling nervousness and ap- prehension of the patient with sedatives and trying to ascertain her obstetric ability; plac- ing no weight on the patient’s outcry. A certain percentage of cesarean sections Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 35 will always be done in these elderly primiparas. due to long standing sterility and the increased value placed on the child. The foregoing shows that too many sections are being done. It carries a greater mortality and morbidity than any other clean abdominal operation. The mortality ranges from 1.8% in clean cases in which operation has been per- formed before the beginning of labor to 27% in cases in which forceps have failed and the membranes have been ruptured for any considerable length of time; while the mor- bidity ranges from 33 to 70%. Now let us pass on to another cause of ma- ternal mortality and morbidity and a high fetal morbidity — use and abuse of forceps and the abuse of pituitrin. The application of forceps still goes on. without any definite idea as to presentation or position of the pre- senting part to the vaginal canal. High, med- ium or low forceps, with utter disregard to the efifacement and dilatation of the cervical -canal, and a lack of any sense of disproportion between the presenting part and pelvic inlet. Only the other night I was called in consulta- tion where forceps had been applied and slip- ped off 3 times, on an R. O. P. above the in- let, with the cervix uneffaced and only par- tially dilated ; entire pelvic diaphragm eviscer- ated out of the vagina, bladder not catheter- ized, the cervix cut in 8 different places, and the fetal skull crushed. This in a young primipara, with a normal pelvis, in labor only 12 hours. Forceps should never be applied above the pelvic brim and only in extreme cases when the head is in the mid-pelvis. Low forceps as your judgment and ability direct. All should be used with great aseptic care and emulating nattire as much as possible. The arrested high heads should be converted into the an- terior positions and allowed to descend. In the minor degrees of contracted pelvis the in- duction of labor 10 days or 2 weeks early gives excellent results, especially in multiparas. Pituitrin is still given in massive doses — -1, 2 or 3 ampules at a time in one labor; given when the cervix is undilated, when the uterus is already undergoing strong contraction ; given without reference to fetal and pelvic disproportion, causing ruptured uteri, cervical tears and hemorrhage, and increasing the fetal mortality by intracranial hemorrhage. Pituitrin should be used with great care and in minute doses, and only when labor ceases to advance because of uterine dystocia. After rupture of the membranes it should be used with extreme caution; never in disproportion of head and pelvis or in thick rigid cervices. In conclusion, let me say that statistics show 90 to 95% of all labors terminate spontan- eously, and that the higher the incidence of operative interference, whether done by the expert or the general man, the greater the in- crease in both maternal and fetal mortalities. Therefore, let us increase our prenatal care, be sure of our knowledge of the physiologic mechanism of labor, practice rigid aseptic technic, keep our conscience ever present, de- crease our interference with normal labor by such instruments as forceps, version and pituitrin, and only use cesarean section after good obstetric consultation. A FEW PROBLEMS IN MEDICAL ETHICS* Harry H. Bowles, Summit, N. J. I wish to express my sincere thanks to the members of this society for the kindness and cooperation they have extended to me during the past year. I know that I have not been so efficient as I should have been, yet you have all been so helpful and considerate that the cares of office have seemed more like a pleas- ure than a burden. One must be bold indeed to dare a dis- cussion of medical ethics. It has been worn so threadbare by repeated handlings that everyone raises an eyebrow when it is men- tioned.- Hence, lest your patience be too sorely tried, I shall make this reading very brief. In the first place it has been, and can still be, said that the right sort of medical man needs very few rules of conduct, while the * (Presidential Address at the Annual Meeting of the Summit Medical Society.) 36 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 wrong sort will be bound by no rules, how- ever rigid they may be. In the last 35 years there has been tremendous progress in the practice of medicine, also in governmental structure and industry, so that many import- ant things have happened to affect the rela- tions of physicians to each other and to the public. One important phase to be mentioned is the employment of doctors by societies, which undoubtedly has a cheapening influence on the practice of medicine. Insurance and fraternal organizations frequently employ physicians to do family practice in a whole- sale way. Corporations made up of laymen employ physicians, and advertise in a com- mercial- manner to attract patrons. Many practitioners are listening to the siren voice of quick money, obtained with little expendi- ture of energy; thus presenting some new problems for medical societies to solve. Where strictly mercenary organizations are concerned, we know the old rule of ethics ap- plies directly. The problem is chiefly con- cerned with borderline cases, where, for ex- ample, a corporation employs physicians on salaries, supposedly to treat indigent cases yet not excluding those which should pay a physi- cian’s regular fee. The question which pre- sents itself here is — can a physician aiming to be ethical become identified with such organi- zations ? Another problem is that of friction which sometimes occurs between physicians of health departments and the family physician. Neith- er is at fault, but trouble is caused as a rule by introduction of the newer methods of pro- phylaxis, vaccine therapy, and so on. Cer- tainly there is some cause for debate as to where the duty of the Health Department ends and that of the family doctor begins. The problem requires tolerance and under- standing for its remedy and no rule of ethics can govern it entirely. To speak frankly it is common knowledge that a considerable portion of the people are not getting the highest type of medical ser- vice. And this is not because of a lack of kindness or altruism on the part of the pro- fession. Medical men still retain the whole- - souled generosity and charitable feelings they have always had, and I think always will have to the end of time. The difficulty appears to lie in the fact that there is a lack of coordina- tion between practitioners and health organi- zations. In the complex civilization in which we now live, individualism has given way to coordinated effort in other lines of community endeavor. The administration of public schools, the building of roads, the regulation of transportation, the regulation of food and drugs, by governmental agencies must meet with our approval. The interest of the gov- ernment in prevention of the spread of com- municable diseases, the control of water sup- plies and sanitary movements, is certainly to be commended. Thus it would seem the government takes care of preventive medicine, the private physi- cians of curative medicine, and it is hard to draw a definite line between them. This small rift or lack of coordination of practicing physicians with health boards and other gov- ernmental agencies, some fear may be an ex- citing cause of ill-advised agitation for state medicine. We have all witnessed the spectacle of state medicine in Europe threatening to demoralize the whole practice of medicine. Some thinkers fear it may seep in here, though we hope not. I believe that state medi- cine would be disastrous for the profession in America and that we should be on the alert to nip it in the bud, should that become neces- sary. We should endeavor to cooperate with all local and state health organizations for the advantage of both sides. I am sure that the profession, so carefully trained as it is to- day, can cope with the situation. We have eaten of the fruit of the tree of knowledge. It remains for the present and succeeding generations to demonstrate that knowledge has been wisely used for the healing of peoples. We must cease to be individualists and must work in splendid cooperation for our fellow- men. Before passing on from this phase of the subject, I merely wish to add that credit must be given to health boards for popularizing, through publicity, the periodic health examin- ations of children and adults. These examin- ations, incidentally, eventually add to the in- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW TERSEY 37 come of private physicians. One state, to my certain knowledge, is trying to institute a system through its health boards, whereby the examination of children of preschool age may be gradually transferred from the domain of the school physician to the family physician. The radio is now being used a great deal for broadcasting important news items to the world. Of course, it is employed in giving to the public' many important fact's regarding scientific medicine and the prevention of dis- ease epidemics: It is perfectly proper for health officers to use the radio in broadcast- ing such news but what about the private physician in a similar situation ? When the latter’s name appears upon broadcasting pro- grams, even if' Inis "meaning is good, he is subject to criticism in the medical family. However, if the occasion were to arise, so that it would seem necessary for one or more mem- bers of the practicing fraternity to broadcast, it might seem more fitting for the local medi- cal organization to select the speaker or speak- ers,' thus avoiding any embarrassment. Another point to be mentioned, we have among the fraternity a few men (fortunately few) who seem to us to be rather heavily in- clined toward the commercial side of medi- cine. These are often the gentlemen with the grand autos, the brilliant plumage, the well- curtained waiting rooms— in short all the “window dressing”. These are the gentry who call every abdominal pain appendicitis, every belch a gall-stone, every heart-burn, an ulcer. Their practice is large, their income huge, their cures miraculous, in the minds of their grate- ful patients. Again, we have the men, and often able men they are, who are endowed with multi-cylindered egos, flavored with avarice, and who exact the ultimate farthing from their patients. These fellows pretend to justify such practices by saying they have rendered unusual service, and that large charges impress the patient with the prestige of the physician. Such acts, of course, vio- late the ethics of practice as much as secret fee-splitting and reflect on the profession as a whole. A little aside from or indirectly related to ethics, yet a phase which medical men should be interested in, is the experiment which is being made to reduce the cost of medical care and hospital expense to the' people of mod- erate means, who do not wish charity, whd wish to pay a moderate fee but who cannot pay the regular fees of hospitals and high priced specialists. Of course, all fair minded medical men would charge but nominal fees to such patients, but what about the hospitals ?' In some of the larger centers efforts are being made to furnish such moderate wage earners with reasonable care, such as combined hos- pital and medical care at $4 to $6.50 per day. Recently there has Ijeen added the Baker Me- morial wing of the Massachusetts' General Hospital to take care of such cases. Presi- dent Embree, of the Rosenwald Foundation,, at the dedication of the Baker wing spoke as follows: “Under conditions of poverty and dependence, charity was a virtue, a human necessity. Today the citizen of America does not require alms, he does not want charity. He wants and rightfully demands that in medical treatment, as in the other necessities of life, agencies be so organized that service will be good and efficient and costs correspondingly low. lie demands this service be not doled out to him as charity but that he be allowed to paV a reasonable and proper cost. Under new con- ditions hospitals should cease to boast of their medical charity, they should take increased pride in striving to have all their services so organized that each patient, even the low wage- earner pays as he goes for what he gets.” These words, bear in mind, were spoken before the great slump in business and vast unemployment came. And the Baker Me- morial started with $1,000,000 endowment and during the first 3 years the deficit will be one-half underwritten by the Rosenwald fund. It will be interesting to watch this and similar experiments. In conclusion, I wish to say that medical men follow a code of ethics which originated in olden times. This code was constructed on the principle of fair dealing of doctor to doctor and doctor to patient. By holding to this code of ethics we can maintain the humanitarian standard on a high plane. In this talk I have meant to be entirely imper- 38 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 sonal and have not meant to infer that the ten- dency of modern medicine is as a rule mercen- ary. Perish the thought. The vast majority of the fraternity are splendid, ethical men ; the ex- ceptional ones are to be considered in some way, I don’t know how. That will be the problem of the societies in the future. In the rapid progress made of late years in all lines of business and the professions it is strange that the adjustments have been so smooth as they have been. It is the duty of such societies as this to help in ironing out the rough spots and paving the way for a broader understanding of physicians to each other, to the profession as a whole, and to the public in general. A BACTERIOLOGIC STUDY OF CHRONIC INFECTIOUS ARTHRITIS John W. Gray, M.D., and Cecil H. Gowen, Newark, N. J. During the past year certain clinical and laboratory observations have been made in the Arthritis Clinic at the Hospital of St. Barna- bas and in private practice, which seem of sufficient importance for at least a preliminary report. The clinic was started primarily for the study and treatment of chronic infectious arthritis (arthritis deformans). Cecil, Nicholls and Stainsby1 did extensive work on this subject. They isolated a strep- tococcus from the circulating blood of pa- tients with chronic infectious arthritis in 61.5% in a series of 7S cases, which organ- ism they considered a specific strain in 83.3%. They also found that streptococcus, culturally and biologically identical with the strain iso- lated from the blood, could sometimes be iso- lated from a focus of infection and in affected joints in the same patient. Cecil’s technic was duplicated and results similar to his were obtained in our laboratory. It was very difficult to get the organism started in primary cultures, as shown by the fact that an average of 17 days’ incubation was required in his series. One of our posi- tives developed on the twenty-eighth day. There was always the suggestion on the part of critics that because the containers had to be opened so many times for subculturing we might be dealing with contaminations. Such a conclusion was highly improbable because we were getting a fair percentage of strep- tococcus growth of uniform type, only an occasional culture showed staphylococcus and diphtheroid organisms, and normal controls showed the same number of contaminants but no streptococcus. Furthermore, Cecil had thoroughly checked his work by animal in- oculation and cross agglutination. However, when tve hit upon a modification of the media about 3 months ago zvhich produced positives in the form of diffuse clouding of the media in 1 to 4 days without opening the bottles, the criticism above mentioned was eliminated. This method which consistently showed more positives than any we had tried, and all in a comparatively short time, presented numerous other advantages from both research and clin- ical standpoints. Cecil’s Plan of Culturing The patient’s arm is prepared by 2 coats of iodin and washed off with alcohol and 20 c.c. of blood is drawn from a vein in the arm and placed in 2 sterile dry test tubes ( 10 c.c. in each). These are placed in the ice box over night. The serum is removed, clot broken up, and the pieces of clot placed in each of two 100 c.c. bottles containing 50 c.c. of media. The bottles are incubated for 30 days and sub- cultures are made on blood agar every 5 days. The media is prepared as follows: Fresh beef heart is freed from fat and fibers, ground finely in a meat chopper and infused at ice box temperature over night, using 500 gm. ground meat and 500 c.c. tap water. Next morning the infusion is warmed to 20-25° and squeezed through a flannel bag. The filtrate is then boiled slowly for 1 hour and filtered through paper. It is then made up to volume and 1.5% peptone and 0.5% NaCl added. This is then placed in the Arnold, for 20-25 minutes to dissolve the peptone and salt. It is then titrated to pH 7.8 and placed in the Arnold for 1 hour. It is filtered through Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 39 paper and retitrated. If the pH has dropped it should be retitrated to 7.8 and put back into the Arnold for another hour. Then 50 e.c. of the media is placed in 3 oz. bottles and sterilized 34 hour in the Arnold for 3 suc- cessive days. It is titrated again and, if it has a pH of 7.6 or slightly above, it is satisfactory for use; if below 7.6, it is unsatisfactory. The finished product should be incubated several days for sterility. Modified Method Preparation of the infusion is exactly the same as above. At the end of the boiling and filtering, 0.5% NaCl, 1% gelatin (Bacto), 1% glucose (c.p.) and 1.5% peptone (Wittes) are added. This is placed in the Arnold for 20 minutes and titrated to pH 8. It is then placed in the Arnold for 1 hour and retitrated. If below 7.8 it is adjusted to that figure and placed in the Arnold for an hour. It is filter- ed through paper. It should not be below a pH of 7.8 before placing in bottles. The bot- tles are prepared beforehand by placing about a teaspoonful of calcium carbonate (c.p. pow- dered) in each of them, plugging with cotton, or cheese cloth and cotton, and sterilizing in the dry sterilizer for 1 hour. In these sterile bottles 50 c.c. of the media are placed and ster- ilized in the Arnold for 30 minutes on 3 suc- cessive days. At the end of 3 days it is titrated and if the pH is 7.6 to 7.8 it is satis- factory. It usually shows a pH of 7.7 to 7.8. The calcium carbonate helps to keep the media from becoming more acid while being steril- ized. If the pH is correct it is placed in the incubator for several days and if sterile is then ready for use. Description of the Organism While the growth is young, long chains are formed which cloud the whole medium. As the culture gets older this clears and the or- ganism breaks up into small chains or even diplococci and settles to the bottom of the con- tainer. Initial transfers into brain broth (Difco) or blood brain broth show the same characteristics. Transfers into a meat in- fusion medium (plain broth) form sand-like flakes which adhere to the side of the tube or settle to the bottom leaving the medium per- fectly clear. After several transfers in this plain broth the organism diffuses through the medium, producing a uniform cloudiness. Long chains which appear in cultures of an enriched medium, such as brain broth or gela- tin dextrose broth, each chain sometimes con- taining as many as 30 to 50 cocci, break up after 24 to 48 hours. The chains are much shorter (6-12 cocci) in plain broth but do not break up until 60 to 72 hours have elapsed. After several transplants the organism tends to grow uniformly in chains of 6 to 12 cocci. On blood agar there is a very delicate growth which shows a definite production of methem- oglobin. This is a very pale green and does not diffuse into the medium but is beneath and immediately surrounding the colony. The colony itself is a dirty grayish color. There is also a small zone of partial hemolysis sur- rounding the colony after 48 hours incuba- tion which is much more pronounced around the colonies deep in the medium. Blood Cultures for Streptococci No. No. No. No. Clinical diagnosis Cases Cultures Neg. Pos. Normal individuals 5 5 5 0 Chronic ulcerative colitis 2 2 2 0 Acute appendicitis 1 1 1 0 Hypertension 1 1 1 0 Purpura hemorrhagica 1 1 1 0 Carcinomatosis 2 8 8 0 Diffuse peritonitis 1 1 1 0 Septic abortion 2 2 2 0 Typhoid fever 1 3 3 0 Cavernous sinus thrombosis 1 2 1 1 Malignant endocarditis 1 4 2 2 Acute peritonsillar abscess 1 1 0 1 Agranulocytic angina 1 3 2 1 Myositis 1 1 1 0 Sciatica 1 1 1 0 Gonococcal arthritis 2 3 3 0 Hypertrophic arthritis 5 13 13 0 Subacute osteitis 1 , 1 0 1 Chronic infectious arthritis 2 2 1 1 (Fluid from knee joint) Chronic infectious arthritis 37 59 34 25 (blood) The above table includes febrile and non- febrile conditions as controls. The malignant endocarditis and quinsy cases showed positive growths of streptococcus which could not be culturally differentiated from the “arthritic” strain. The positive culture in the case of cavernous sinus thrombosis was a typical Streptococcus viridans. The patient suffer- ing with agranulocytic angina had a septic throat and pyemic abscesses. Hemolytic streptococcus was found in the blood culture. 40 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 The subacute osteitis case was of unusual in- terest because of its close clinical and bac- teriologic relationship to the infectious ar- thritic group. The patient complained of moderate pain in the lower thigh for about 4 months, had a low grade tempera- ture and radiograph showed thickening of the bone. Three diseased teeth were extracted soon after the onset. Vaccine was prepared from the “arthritic” type streptococcus iso- lated from the blood. The streptococcus re- covered from the knee fluid was identical, cul- turally and morphologically, with that re- covered from the blood stream and occurred in one of the cases listed under chronic in- fectious arthritis, a woman of 56 years who gave a history of arthritis for 15 years and was badly deformed. The chronic infectious arthritic group of 37 cases in which 59 blood cultures were taken showed a positive growth of the “arthritic” streptococcus in 67.6% of the cases and 42% of the cultures. The cases placed in the above group showed many variations but were sufficiently typical clinically to be so classified. They all had multiple arthritis, most of them typical fusi- form swelling of the smaller joints and many had deformities. The youngest was 14 and and had suffered involvement of the joints of the hands and feet for 4 years (Still’s dis- ease). The oldest was 75, the average age 44. The duration of illness was from 3 months to 25 years ; the average duration being 5 years 2 months; 29 were females, 8 were males. Several cases classified as chronic in- fectious arthritis showed interesting varia- tions. Two patients, a woman of 40 and a man of 60, had severe bilateral rheumatic iritis which developed prior to onset of arthritis. Both gave histories of severe sinusitis. One patient of 29 first noticed pain in one finger, developed tenosynovitis with a “trigger” finger and subsequently typical arthritis. Three gave histories of rheumatic fever or allied condi- tions in childhood; 2 of these had definite at- tacks of rheumatic fever, 1 had chorea and myositis. All had rheumatic cardiac signs. In 1 . interphalangeal joints of the hands showed fusiform swelling typical of early deforming arthritis, while the other 2 had multiple de- formities. Two showed “arthritic” strep- tococcus in blood cultures. We are not in a position to determine whether the rheumatic fever infections or secondary infections were the etiologic factors in these cases. Of the chronic infectious group, 30% showed definite foci in teeth, tonsils or sinuses. In the hypertrophic group no his- tory or evidence of foci were found. Cecil recently stated that patients with typi- cal chronic infectious arthritis show high agglutination for the typical arthritic strains in 94% of cases. This would be important not only in proving the specificity of the or- ganism for this type of arthritis but also in differentiating border-line infectious and non- infectious types. We have examined most of our cases for agglutination of these organisms and find that many of the bloods show a posi- tive result to a high titre. However, no fur- ther report of this phase of the work can be made until proper controls are carried out. Chronic infectious arthritis is undoubtedly due to a streptococcus infection of the joint tissues caused by a blood stream infection from a primary focus such as the sinuses, teeth and tonsils. Probably some patients control foci in the joints without any treament, others apparently recover when the primary focus is removed, but the great majority do not con- trol the secondary foci in the joints and stead- ily or intermittently progress toward deform- ity and invalidism. Vaccine therapy has been persistently used in the belief that it would have a specific action on the joint infection. The vaccine was pre- pared from the “arthritic” streptococcus iso- lated from the patient’s blood or from prim- ary foci, or both, or from typical strains in case an autogenous vaccine could not be ob- tained. A primary dose of 200 million was given, increasing that amount each week until 2000 million was given as a maximum dose and that amount was continued indefinitely unless a reaction occurred. Because of re- current attacks in 2 patients while on this regimen, focal or general reactions were con- sidered indications for reducing the dose. The most important single observation regarding Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 41 vaccine therapy was that it must be used for a long period of time. One must have a great deal of confidence in this method of treat- ment to encourage patients to continue injec- tions for months with little or no apparent change in the joint picture. But we have been repaid for persistence in many instances by a sudden improvement which progressed to an apparent cure. However, one should not expect too much from vaccine alone. Some patients are acute- ly ill and require hospitalization. A large number are poorly nourished and require a high caloric diet. Two patients who had in- sufficient vitality to respond to vaccine or any- thing else were given initial transfusions. Many patients find it necessary to continue work, using up every ounce of their reserve, when they deserve long continued rest. Fa- tigue should always be avoided. A warm, dry, equable climate is ideal. Although we are par- ticularly interested in prevention of deformi- ties through early and possibly specific treat- ment, there are thousands of crippled people who could be infinitely improved through proper physiotherapeutic and orthopedic treat- ment. They cannot receive adequate treat- ment at home and there are few hospitals for the care of such patients as cannot afford a private sanatorium. It is obvious that because the group of cases treated was small and because of the short time they have been observed no final con- clusion can be made until a later date. Nor would we venture too far in making con- clusions regarding: the cultural study, but we do feel that the method above described for the quick growth of organisms from the blood of patients suffering from chronic infectious arthritis is of sufficient importance to be brought to the attention of other workers at this time. References • 1. Cecil, R. L., Nicholls, E. E., and Stainsby, W. T.: Bacteriology of the Blood and Joints in Chronic Infectious Arthritis, Arch. Int. Med., 43: 571, 1929. 2. Cecil, R. L. : A Modern Conception of Arth- ritis, Jour. Lab. and Clin. Med., 15:1177 1930. TODAY Yesterday, I know not how, I slipped out from Then to Now. Such a world before me lay, Growing fairer every day, ’Til this morn I pause to count All my wealth — a vast amount : Friends, the love that round me lies, Flowers and birds and sunset skies, Memories of what hath been, Hope for days that wait unseen; But the best in every way Is the gift of each new day ! Every morn for me it waits, When I drift through sleep’s dim gates. None may hasten, none delay, None may spend it — My Today. So this little prayer I raise For today and all the days : Joyfully may I fare forth, Make each swift day full of worth, Work and love and pray and live And myself for others give. So may life be richer when I am sped from Now to Then. Frances, C. Hamlet. 42 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Special Article MEDICAL TRAVEL TALK A Physician’s Vacation in Ireland, England and France Henry O. Reik, M.D., Atlantic City Physicians find it more difficult than any other class of workers to take a real vacation, if by that word one means putting aside thought of the daily occupation, for the prac- tice of medicine is not only a noble profession but a very exacting one, and when one becomes wedded to it he finds himself bound to a jeal- ous mistress who demands constant attention. and explorations. A short post-graduate course of study may be made to serve the purpose of vacation, as may also attendance upon some national or international medical convention. Or, inasmuch as travel has both a vacational and educational value, even an informal trip into distant states or other coun- tries may prove profitable if combined merely with observation, from a medical point of view, of the habits and customs of other peo- ples. It was with some such vague idea in mind that we planned this summer’s vaca- tion ; we had no desire to listen to the reading of scientific papers, nor to attend clinics, but we believed it might be possible to pick up some information concerning the working of national health insurance laws — sometimes referred to as State Medicine — while at the same time enjoying the delights of travel, and, *!* : sfsaasB'.v-'sr : .. . m ilia ■■ fmm* r : i gsiiti ' v *»K m win ii 81 IS Fig. 1. Village Dispensary. District medical service to the poor: under a very old law. On the other hand, no group of workers de- serves more than physicians or is in greater need of periodic vacations, if by that term we mean a surcease from routine labor and substi- tution of new scenes and thoughts. Properly speaking, vacation should embrace change of climate and variation of mental activity, rather than complete cessation of labor, for it is from changes that one procures that bodily rest and cerebral stimulus which tend to re- store healthy vigor. Thus we may find a happy medium, between complete loafing and constant work, fitted to the conditions that affect most medical practitioners. The physi- cian can take a rest from his usual routine of labor and yet continue in touch with some of his vital interests ; can do this perhaps better than other workmen because there are so many fields into which he may extend his studies .further, to secure some interesting pictures of foreign medical institutions. So, we took along a “Filmo” and proceeded to record some moving events. In the beginning let us say that the often heard excuse — “I can’t afford it” — is not a sound reason for not taking an annual va- cation. No man who is doing or wishes to do high class professional work, and that should apply to all physicians, can afford not to take an occasional vacation. Few better invest- ments exist, for the profits — renewal of en- ergy and preservation of health — are certain and immediate. Nor need the cash investment be very large. True, travel is more expensive now than in former times, just as the cost of everything else has increased, but it is not sufficiently high to be out of reach of the average practicing physician provided he is Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 43 willing to travel on a moderate basis. Con- sider, for instance, a European trip embracing visits to great medical centers, whether for clinical study or simple observation of insti- tutions and passing events ; a vacation of 2 months duration can be financed on less than $1000, with due allowance for living in first class style; a single month of absence from home, which covers 2 weeks on the ocean and 2 weeks abroad need not cost more than $600. Of course, if one feels it necessary to travel on the “ocean greyhounds” and to command all the luxuries of the most fashionable liners, more money can be expended ; but such a course of action is by no means necessary to a beneficial vacation. We have crossed the Atlantic many times, and have tried all types of boats, and experience has resulted in the jumping off from Baltimore, in the County of Cork, the southernmost point of Irish land, and landing in Baltimore, Maryland. It happen- ed that our ship landed us not far from the northern extremity of Ireland, i.e. in Belfast, so we had to traverse the entire length of the country. We are not inclined to recommend booking to Belfast unless you have some very special reason for so doing. However, the fact that we sailed around the northern coast and close enough to procure a good view of the land in the late afternoon and early evening hours, compensated in some measure for the discomforts of landing ; for the ship was an- chored in the Irish sea and we were sent ashore on a ferry-boat which consumed 2 hours passing up the bay and river, to put us on the dock at 3 a. m. Sunday. It is far more Fig. 2. Merrion Square. Specimens of doorways. American Consulate at right. conviction that the greatest comfort and satis- faction are obtained from the modern “cabin” boats; such ships as the Samaria, Carmania or Aurania, of the Cunard Line, and the De Grasse or Lafayette, of the French Line, offer all the necessary conveniences, perfect comfort and excellent food, and are in some respects preferable to the larger boats of the same companies. The round trip can be made on any of the boats named for $300 to $500, according to size and location of room, and, $10 per day is ample allowance for the time to be spent on shore. Remember this when preparing next year’s budget. Having on previous voyages neglected Ire- land, we determined to commence this time with that country ; partly because we had a desire for new sensations, and partly because our maternal great-great-grandfather migrat- ed from the Emerald Isle 150 years ago — comfortable to enter Ireland by way of Queenstown (Cobh), where facilities for landing are much better. Belfast has few attractions for the tourist; in fact, we can think of none except that it con- stitutes a good approach to the Giant’s Cause- way, if you care to visit that freak of nature, and that a side trip can be made by auto-bus over a beautiful driveway which follows the northeastern coastline for a considerable dis- tance through County Antrim — a road running along the edge of the cliffs much as our own Hudson and Bergen County Boulevards fol- low the course of the Hudson River along the Palisades. Belfast is essentially a commer- cial city, in the midst of a manufacturing district, and except in the newer residential portion has a drab appearance, though the public park and suburban area redeem this to some extent. The surrounding country is 44 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 charming, but that can be said of practically every square mile of Ireland. From the first glimpse of green behind the rocky coastline, to the farewell view as we crossed to Wales, we were conscious that the sobriquet— Em- erald Isle— is most fittingly applied. No green we have ever seen has been greener, and no land we have yet seen offers anything superior to the fertility of Ireland’s soil. Everywhere, from north to south, from east to west coast, the land is a rolling terrain, and everywhere it is covered with a luscious growth of plant life ; a sight to please anyone with a countryman’s soul and a farmer’s eye. Across the boundary line into the Irish Free State and we entered Dublin. The austere, sombre appearance of Belfast gave way to the contrasting brighter and gayer modern American cities ; and we were soon to discover that in Ireland it is the general custom. On our first car ride, we requested the conductor to tell us when we should be arriving at the point nearest to Dublin Castle. After some little time, a gentleman leaned across the aisle and said: “I heard you asking for Dublin Castle. If you will get off at the next corner, where the car will turn, walk one square farther on this street, and then turn to your left, you will be facing the Castle.”i This was kindly intervention, for the conductor would probably have forgotten us because of other demands upon his time. On other occasions, when asking for informa- tion, people put themselves to considerable trouble to render assistance. Such experiences naturally led to conversations from which we Fig. 3. Ruins of the Castle from whence came the Donohoes. capital city of the recently organized Irish Re- public. The fact w'as brought strikingly to our attention by the coincidence of making our ad- vent at the same time as the first French Am- bassador to Ireland. An American Ambassa- dor was installed some time ago, and while watching the procession attendant upon the French Ambassador’s reception, a kindly Irish gentleman gave us an interesting discourse on the local political situation, and, also, a lessoi in Gaelic. And right here let us take advantage of the opportunity to say that nowhere else in the world have we met such uniform cour- tesy as we found throughout Ireland. Our first surprise came upon entering a crowded street car, and observing that the passen- gers moved to make room for us to sit down ; such a delightful contrast to conditions in gleaned valuable knowledge in addition to what we had originally sought. Also, some of these experiences were amusing as well as interesting, for the Irish wit found abundant chance for display. Our Gaelic friend, while watching the am- bassadorial parade and discussing various sub- jects, drew for us a comparison with relation to the Irish Free State's desire to take life easily, saying: “We are not inclined to rush and hurry, but prefer to take things slowly. I had a friend, of about my own age, who was always urging me to be more ener- getic and do more business. He was not satis- fied with business life in Dublin, and so he went to Belfast and then to London, and he worked hard, and he succeeded in making money and building up a large business, but — he has been Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 45 living in a cemetery for 10 years, and I am still hale and hearty.” And he was a remark- ably well-preserved, patently successful man considerably beyond the allotted three score and ten years of age. From the medical point of view our inter- est in Dublin centered in Trinity College and we spent most of our first day inspecting that institution. Trinity is, as you probably know, one of the world’s notable universities, and dates from December 29, 1591, when it was established by royal permission of Queen Elizabeth. One of the chief points in esti- mating the success of any form of govern- ment is found in the attention paid to the sub- ject of education, and we were interested to learn the plans of the Irish Free State in this respect. The Irish Times of Saturday, Aug- (generally spoken of as Trinity College), is of recent birth — only about 20 years old — and has not yet attained any particular renown. It is the present policy of the government to in- sist upon the study of Gaelic in all the public schools ; an order that seems to have greater sentimental than practical value. Trinity, with its 340 years of growth, has become an institution of imposing appearance and great national importance. The grounds form a lovely park and the buildings are pleasing from an architectural aspect, but the Library is the center of attraction to anyone at all interested in educational affairs. Like Oxford and Cambridge, this University has always received under British law a copy of each' book published in the United Kingdom, so that its library contains today more than Fig. 4. Lake ICillarney at twilight. ust'9, carried an explanation of the public school system : compulsory school attendance up to the age of 14, when a “Primary School Leaving Certificate” may be obtained upon satisfactory passage of an examination; sec- ondary educational curriculum providing for “Intermediate Certificates” after 2 years’ fur- ther study (showing ability to take up ad- vanced work or to enter technical schools) and final “Leaving Certificate” at the close of an- other 2-year period; and, “Honors Certi- ficates” when pupils’ marks justify the award. The leaving certificates have a definite value inasmuch as they are accepted for matricula- tion in the National University of Ireland, and accepted with certain qualifications for en- trance to Trinity College. The National Uni- versity, which, by the way, must be dis- tinguished from the University of Dublin 300,000 volumes of exceptional value for ref- erence purposes. Then, claim is made locally that the most valuable book in the world is in the possession of this library ; that is, the famous Book of Kells, a marvelous piece of illuminated text of the gospels, the life work of one monastic scribe in the eighth century. This book is carefully preserved and is under supervision of a special caretaker; each even- ing it is placed inside a steel vault, and each morning is opened at a new page and placed in a glass case for the inspection of visitors during the day — the opening at a different page daily being designed to avoid too pro- longed exposure of any given page to the ef- fects of daylight. Trinity is located in the very heart of the city, the entrance being directly opposite the old Parliament House, which is now used as 46 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Tan., 1D31 the head office of the National Bank of Ire- land, and the chief buildings are ranged along the 4 sides of an immense quad the center of which constitutes a small park containing many beautiful old trees. There is an inner court, containing dormitory buildings, and at the distant end of the outer quadrangle stands the Medical School with its anatomic and physiologic laboratories. In 1654 the College of Physicians was established in connection with Trinity College, and this connection is still maintained in the choice of professors for this medical school. The medical school buildings are not very ancient but they were undergoing reconstruction during the period of our visit and the Sunday paper contained the following interesting and witty news item : structure to the sister association buildings in London. It might be mentioned, too, that the British Medical Association has a separate branch for Ireland, with a resident secretary and office in Dublin ; but of our visit to that institution we will speak later. The region between Trinity and St. Ste- phen's Green, embracing both Kildare Street and Merrion Street, is rather fashionable and contains many fine old houses that intrigued us because of their beautiful front doors. Perhaps the greatest mark of distinction about the external appearance of an Irish home is the portal of entrance; the architectural beauty of the facade hangs particularly upon this feature of the plans and many of these houses have doorways of striking character. The doors are made of fine woods, mahogany Fig. 5. Typical Irish Village Market Day. A Warm Time Cominc “For some time now workmen have been busy at the medical school, putting in new heating ap- paratus. A new boiler of formidable proportions was taken in through the front door — various walls and windows having to be demolished to permit its passage — and duly lowered into the depths. In connection with the complicated arrangement of engines of torsion and leverage, which were rig- ged up to get the boiler into its new home, a curious incident occurred. A steel cable stretched some 6 ft. above the path smashed the windscreen of the car of Dr. E. J. Watson. Had Dr. Watson been decapitated, as he so nearly was, the Rugby Club would also have lost its head; for he is its President.” We were interested also in visiting the very, old homes of the Royal College of Physicians, on Kildare Street, and the Royal College of Surgeons, on St. Stephen’s Green, 2 of the fin- est buildings in Ireland and quite similar in predominating, and the woodwork, as well as the brass knocker, is kept in a state of high polish. Furthermore, they are protected from the effects of inclement weather and the sun’s heat by canvas covers that may be adjusted as seems necessary. The fan-shaped tran- soms, behind which in some instances one ob- serves a marble statuette of some animal or the bust of some distinguished man, add to the interest as well as the beauty of these entrances. Leinster House, once the residence of Lord Edward Fitzgerald, is now used as the meet- ing place for the Irish Parliament. It is flanked on either side by the National Library and the National Museum ; the 3 buildings forming 3 sides of a hollow square. Old Dublin Castle, for many centuries the center of political authority, is now being used as a Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 47 temporary home for the High Courts and as offices for other divisions of the government pending reconstruction of the buildings par- tially destroyed during the revolution. On the occasion of our visit to Dublin Cas- tle. we had an unique experience. After hav- ing been shown through most of the galleries and some of the rooms that are not ordinarily opened to visitors, our guide took us into the court chamber where a case was being tried and extended the courtesy of following the proceedings so long as we might be interested. The most impressive feature to us was the manner in which the trial judge endeavored to dispense justice ; a striking contrast to some court scenes we have witnessed in this grand and glorious United States. The case under concerned.” Here was a judge ready to push aside technicalities, in order to effect a full measure of justice. Certainly a pleasing sight in these days. Our wish to photograph many interesting and historic spots in Dublin was interfered with by weather conditions. During the first morning of our stay in the city we started out with camera in hand but found a shower of rain and returned to the hotel room for an umbrella. As the elevator descended with us for the second time within a few minutes we apologized to the operator for not having properly prepared ourselves at first, and then asked whether it rained often in Dublin. His answer was : “An umbrella is a useful thing to have, sir, in Dublin, for you will Pig. 6. View of Blarney Castle; indicating location of the famous charmed stone. consideration concerned the disposal of prop- erty left by some one’s Last Will and Testa- ment, and the administrator, some fiduciary company, was trying to force all of the lega- tees to comply with orders of his own. The attorney for the plaintiff had explained the situation and requested an order of the court to compel obedience. The judge listened at- tentively and then said, in effect, something like this: “Before calling upon the defense to reply, I think I should say to you, sir, that I realize you are trying to take advantage of a technicality of the law, and that while you may have a legal right so to do, I am not in- clined to grant your request, for the simple reason that such a decision would possibly work great injustice to some of the parties meet another shower about every second street crossing.” His words proved to be quite true not only for Dublin but for all of Ireland during the 2 weeks we spent there. If we can feel that it is a beautiful, charming coun- try, in face of the continuous wet and cold weather of this past summer, it must be some- thing wonderful to see during a sunshiny period. The Killarney lake region seemed to us deserving of all that Tom Moore wrote and that John McCormack sings about it; veritably, “a little bit of heaven”. The nearest comparable thing in America, in so far as we can recall, is Lake George, but much as we love this favorite spot, we are compelled to admit that Killarney possesses even greater charm. There is a bewitching beauty, a poetic 48 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 softness and delicacy, about Killarney that is all its own, and we earnestly recommend it to you for a short visit, or a prolonged so- journ, according as you can afford the time ; but do go there sometime during your life if only for a fleeting glimpse. One can make, as we did, a very delightful circular tour from Dublin to Killarney, thence to Glengariff and other points on the south coast, across to Cork and up through Tipperary to the capi- tol city again, and every mile of the way will be enchanting. In the cities, and in every town through which we passed, generally close to the town hall or to the church, we observed Public Dis- pensaries, and our first thought was that these its application to the 3 northern counties that remain a part of Great Britain. This infor- mation, with much more of interest, was ob- tained through 2 very pleasant hours spent with the Commissioner of Health of Dublin, Dr. Russell, and the Secretary of the Irish Section of the British Medical Association, Dr. Hennessy. Dr. Russell had visited the United States 2 years ago when the Rocke- feller Institute conducted a tour of foreign public health officers to study American meth- ods, and Dr. Hennessy had practiced medicine in England before and for a time after adop- tion of the National Insurance Act, so we were able to secure considerable authentic informa- tion concerning medical conditions ; facts Fig. 7 Kissing the Blarney Stone consists in hanging head downward into the opening and placing the lips against the under surface of the basic stone in that portion of the outer wall at the end of the iron bars. One has to hold firmly to those bars, and it is advisable to have a friend hold the kisser’s feet, to prevent an accidental fall resulting from dizziness. were part of a national health insurance plan, but upon inquiry we discovered that under a very old law of the country free medical service is provided for the poor, and each district of a certain size has its own dis- pensary, the attending physician being a paid, part-time, official with the privilege of private practice. The British Health Insurance Act was meant to cover Ireland along with the rest of the United Kingdom but in Ireland it met with even less recognition than our national prohibition law has been accorded in some of the states ; in fact, throughout Ire- land, it was simply ignored until 1928 when action by the League of Nations resulted in which will be utilized for discussion at a later date. While we were in Dublin, however, the i Irish Times published the following item: Medical Benefits The Irish Medical Committee has passed a reso- lution drawing the attention of the Saorstat (Irish Free State) Executive Council to the establishment of a system of medical benefits in Northern Ire- 1 land, and suggesting steps be taken to provide medical treatment for insured persons in the Free State, preferably by the establishment of a na- tional medical service on the terms suggested in the Majority Report of the Committee of inquiry on the National Health Insurance and Medical Services. (To be continued) Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 49 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J.t as second-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact. NOTE. — The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to The Editor, Atlantic City, N. J. _ . All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. THE PRESIDENT’S NEW YEAR GREETING The President of the Medical society of New fersey takes pleasure in greeting the membership in the New Year. He extends his best wishes for a yrear filled wfith the joy of work well done. He hopes the Great Physician will shower blessings upon the mem- bership and give them wisdom to cope with the serious problems with which they are faced. To the Womans’ Auxiliary he pledges his interest and support in its noble and unselfish efforts to aid in promoting the aims and ob- jects of the Medical Society of New Jersey and to serve as an ally to that organization in developing its program of health education and public welfare. George N. J. Sommer. FRACTURES AND THE COMPENSA- TION LAW In the December Journal we published an interesting discussion of the practical working of the Workman’s Compensation Law, started by Dr. Sherman’s paper on Eye Injuries. This month we present an excellent corollary to that review, in the papers by Drs. Adams and Martin, on Fractures and Traumatic Surgery, and the accompanying discussion. Taken to- gether, these contributions pretty nearly cover the complications and difficulties that inter- fere with a smooth working of that law. You will profit by reading the matter in its en- tirety. We may at the same time report that a spe- cial subcommittee of the Welfare Committee is now engaged in studying a plan for smooth- ing out all the disagreements that so common- ly arise between physicians and compensation insurance companies. A PROBLEM SOLVED. IOWA PLAN OF SECURING PAYMENT FOR SERVICE TO THE COMMUN- ITY’S INDIGENT SICK The Annual Conference of State Society Secretaries and Editors, held at Chicago in November, provided this year some discus- sions of exceptional interest. President Som- mer accompanied your regular representatives, and in the Department of Communications you will find a letter from him relating his impressions. The Department of Lighthouse Observations is also being utilized this month for presentation of a summary of one of the most important papers read at that confer- ence ; a paper dealing with the relations of the medical profession to the public, and especially to the much talked about problem of state medicine. It remains for us to direct your attention to a paper presented by Dr. Robert L. Parker, Secretary of the Iowa State Medi- cal Society, under the title, “The Best Method of Caring for the Indigent Sick”. During a visit to one of our county societies recently we heard a somewhat heated dis- cussion concerning the relationship between the local physicians and the Board of Free- holders, with special reference, apparently, to 50 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 the disinclination of county authorities prop- erly to compensate physicians for services ren- dered to the indigent sick. Furthermore, a situation was reported last month by the Essex County Medical Society, indicating that the Newark City authorities and the county society are endeavoring to reach an agreement whereby the city’s indigent sick will be prop- erly cared for and the physicians will be paid for services rendered. The Iowa plan for providing adecjuate medical services to im- poverished citizens, securing to physicians payment for services rendered, and avoiding disputes, seems to us peculiarly applicable to some of our own county conditions. Briefly stated, the Iowa plan provides that the county medical society shall make a blanket contract with the county authorities, under which the latter will pay annually a fixed sum to the society in return for proper medical care, by members of the society, of all the in- digent sick in that community. Such medical attention is to be supplied upon orders of the freeholders (or whatever may be the official name of the county authority) ; and such ser- vice is divided among members of the society on as nearly an equable basis as possible. The total annual payment goes into the society treasury, to be disposed of as may be deter- mined by the organization : members may be paid out of this fund for services actually ren- dered ; the unexpended balance may* be used as the society sees fit ; or, members may con- tribute their services without pay and permit the society to utilize the entire fund for the benefit, in some other form, of all its mem- bers. Consonant with the last mentioned de- vice, some of the Iowa counties have found this money sufficient to relieve members of the entire burden of dues to county, state and national societies ; some propose using the growing fund to establish an endowment; some purchase insurance and indemnity poli- cies for all members, on the group basis ; and some use all or part of the fund for bringing speakers from a distance, thus relieving the program committee of a burden, or for con- ducting post-graduate courses. The income of the county society, from this plan, varies in accord with the population of the countv ; and the sick demand varies with its percentage of indigent citizens. In Iowa, the plan has been tried for a few years in 1 1 counties. The population ranged in these counties from 16,000 to 63.000, and the con- tractual payments ranged from $1600 to $12,- 600. In general, the obligation was to furnish full medical service, including major surgery when necessary, and medicines and supplies except serums, antitoxins and salvarsans. It will be noticed from the above figures that the smallest county paid on the basis of 10c for each member of the total population, while the larger county paid upon the basis of 20c. The total population of the 11 counties being 316,201, and the total amount of money paid into the 11 county medical societies $36,530, you will observe that the average payment was upon the basis of a trifle over 1 lc per citizen. The membership of the smallest county so- ciety numbered 10; of the largest county, 86; the average being 36. As the total registered membership was 370, and the total fund $36,- 530, the average allotment for each physician might have been a little less than $100. In some of the counties the work was per- formed by assigning patients to the nearest physician ; in some instances arrangements were made whereby members of the county society rotated in service; in some counties the pa- tient was permitted freely to select his own physician from the county society member- ship. As indicated, the plan worked admirably in so far as it has been tried in the state of Iowa. It has resulted in physicians being paid for services rendered to the indigent sick* just as other services and supplies to such citizens are paid for by the community ; thus eliminat- ing the injustice of placing upon physicians alone the burden of caring for the sick poor. It has further resulted in a general satisfac- tion of the community with its physicians through this supplying of effective medical service to the needy, and it has also resulted in the removal of friction between physicians and local boards of supervisors and social workers. Finally, it has served to provide the county society with much needed funds to carry on scientific or educational work. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 51 Economics THE OPEN HOSPITAL William H. Ross, M.D., President of the New York State Medical Society, Brentwood, Long Island, N. Y. There is no other practical way of bridg- ing the gap between the time of a doctor's graduation in medicine and the present day knowledge, than by experience in a hospital. Practically, this is possible for all of the pro- fession in an open hospital. Much has been written about the merits of an open or closed hospital but considering the educational in- fluences on the profession, an open hospital is of greater community value. In no other way can the profession be kept in the proper state of education regarding modern medicine than by continuous education in its own environ- ment. It is not the primary obligation of hospitals to undertake to make specialists and it is the obligation to train the 80% of the profession who are general practitioners and who attend to that percentage of care of dis- ease. If those who manage hospitals do not make them available in some way to the entire pro- fession for practice therein, so as to benefit by the education that flows from them, we are not protecting the public, by making good doctors, from that ever present tendency of the human mind to credulity and the unusual nor are we developing availability of the science of prevention and cure of disease — an ideal that came to the front in the initial meet- ing, in 1807, of the Medical Society of New York State when it offered a prize greater in value than its then entire financial resources for the best method of prevention and cure of Typhus Mitior. I believe that with the 1,000,000 hospital beds in 9000 hospitals and the increase of 127% in hospital facilities in the last 20 years, the time has come when every doc- tor should have a hospital connection un- der some plan. A hospital does much for a community. It sets up an advanced standard of practice. In addition to making better doc- tors it becomes a real source of education to the public and steadily breaks down medical ignorance, the greatest foe of public health advance. Medicine has done much for human wel- fare and for civilization, and the education that flows from a modern hospital can con- tinue this and make it the greatest modern factor in advancing these age-old functions of the profession of medicine. In New York City and its metropolitan area, the educational advantage offered physicians seems consider- able when we realize that 51% of doctors have hospital or out-patient service, 16% of the remaining are either retired or engaged in other phases of medical work, leaving 34% who are without institutional appointment, but since there are in New York City 10,877 physicians, 3698 are by the present system of hospital service largely deprived of the oppor- tunity of continued education. The only im- portant difference that I know of in the medi- cal situation in New York City is that there is 1 physician for 550 people and in the rest of the state the average is 1 for 793 people. You may draw your own inferences regarding professional attitudes toward clinics, health centers, and the economic situation, and efforts to improve it. The question arises — is organized medicine meeting its obligation to provide the best kind of physicians that it can ; and right here I would like to say that which I have said on several occasions this year, that it is time for organized medicine to self-appraise its own organization and offer proposals for the solu- tion of problems that government has taken on in 23 other countries, if the profession is going to avert more state medicine. The rural hospitals of New York State are generally open hospitals and their standards of practice are good. Human nature is about the same in rural as in urban sections. If an open hospital brings about arising of the level of professional ability of practicing physicians and prevents a loss of professional prestige, and gives the patient the right to select his own physician, insuring personal interest and responsibility' for his welfare, then it is worth trying in cities and the few remaining places in the country under the guidance of medical statesmanship with rules, regulations, and penalties for enforcement of standards to see if it does not work out as well as it now works in many small communities in New York State doing work equal in results to the av- erage city hospital. My experience in hos- pital organizations makes me believe that the essential control is compulsory staff confer- ences to review the catastrophies and to record the story of diagnosis and treatment, so that a strange doctor reading it would understand the case, and, then to file the record so as to be easily accessible for study. Sometimes I think that perhaps our own profession is dividing itself into 2 classes — one the conservative, guided by tradition ; the other the liberal, interested in human progress. 5.2 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE\ Jan., 1931 Collateral Reading THE FUTURE OF FREUD The Structure and Meaning of Psycho-analysis By William Healy, Augusta F. Bronner and Anna Mae Bowers {Reviewed by Joseph Jastrow in Saturday Review of Literature, June 28, 1930.) Despite the increasing numbers to whom the ideas underlying psycho-analysis have be- come familiar, the recent restatement of “Freud” by Freud is relatively unknown. His disciples have , carried on a campaign of ex- position of the clinical phases and their bear- ing on life problems and the interpretation and organization of human motives. The di- vergent views of Jung and Adler, of Adler notably, continued the same emphasis with more liberal interpretations. Yet through it all the starred feature is the origin of the neurotic trends and the technic for their con- trol. Dr. Freud shows the characteristic tendency, as thinkers approach three-score-and-ten, to lose interest in the collection of data and focus upon the fundamentals which now, as of old. implies a philosophy. This is equally true of William James and Wilhelm Wundt, two other master minds. Freud’s interest in clin- ical psycho-analysis has given way to its theoretic formulation, which in truth is not “psycho-anal ysis’Jat all ; Freud calls it “meta- psychology”, which supplies in the apt title of Dr. Healy ’s notable book “the structure and meaning of psycho-analysis”. A correctly perspective view of the Freu- dian psychology is not likely to arise in the clinical camp of Freudians. They are too closely absorbed in the intricate psycho-analyz- ing of “cases,” whose complexity they tend to exaggerate, and whose diagnosis they coerce into conformity with accepted doctrines. There is in all a marked cultist streak which is not conducive to reflective clarity or ob- jective sanity. The contribution of Dr. Healy, Dr. Bron- ner, and Miss Bowers may be accepted as a long anticipated recognition of the develop- ment of Freud’s views as a theory of psychic motivation. Dr. Healy is not a psycho-analy- tic practitioner; he holds no brief for any school or cult. He utilizes the psycho-analytic approach in the handling of personality and be- havior problems of a far more varied and directive character than appear in a neuro- logic clientele seeking relief from oppressive conflicts. He is a broader type of clinician; and it is fortunate that he has included among his interests that of setting the Freudian house in order. While I expected such a book to appear in due course, it was my further anticipation that it would be devoted to the clinical phase of psycho-analysis. This is still an urgent de- sideratum and would form volume 1 of the magnum opus of which Dr. llealy and his associates have given us volume 2. The method adopted in this book is well adapted to the purpose in hand. It consists of a large- type text on the left hand pages, stating Freud’s own formulations, with a commen- tary on the right- hand pages in smaller type, setting forth the variant views of followers and dissenters — a psycho-analytic Talmud. It requires a close knowledge of the subject to follow this exposition, a far more sustained interest than even the well versed student of psychology is likely to command. lo the serious student of the subject it is an indis- pensable guide. So much for the right hand text indicating the purpose and temper of the volume; and now for my left hand comment which, I fear, will in some circles be regarded as a left hand- ed compliment. For the fundamental ques- tion that readers of reviews of books-to-be- read will ask, relates not quite to the structure or the meaning, but to the significance and value, and the ever persistent truth of it all. Freud is weak, whether by temperament or training in the architectural sense; he erected his edifice as a series of facades and additions, with a ground-plan supplied as he built. Now, retrospectively, he makes good his deficit, yet never with the skill of Dr. Healy’s penetrat- ing pragmatic gift. The “cardinal formula- tions” are libido, cathexis, polarities, ambival- ence, the unconscious, preconscious, and con- scious, the “id”, the ego, and the super-ego, the fundamental principles; pleasure and reality, Nirvana and compulsion, the Eros or life instinct, the death or destructive instinct. All of these have their developmental stages ; a life is a genesis and a growth. They have their constitutional patterns strongly influ- enced by early experience. They disclose me- chanisms, here better called dynamisms ; and they end in character and personality, and there find their consummation and justifica- tion. Therapy is but an application and ap- pears in the concluding chapter alone, how- ever closely theory follows, the clues of clini- cal findings. This bare enumeration and its unintelligi- bilitv until elucidated, make it clear that the Freudian metapsychology is a new science, or shall we say speculation? It requires a new Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 53 vocabulary, a new approach, a new set of concepts. This story of the lify of the mind is completely different from ithat of the stand- ard psychologic versions of whatever origin that occupy academically and practically the great body of contemporary psychologists. If Freud holds the clue, they are pursuing false trails. Has Freud made good? is the question. For what all this means for the understanding or management of a human life can but be hinted at in a review. If lives and personalities are but Freudian exhibits, then for the great majority life is lived with a minimum of un- derstanding. It means that we are fearfully and wonderfully, sexualized, not merely the lower centers of our protozoic past, now sur- viving as the “id”, but equally the higher cere- bral areas where ego rules' and the super-ego soars, starting, like an airplane, with wheels on earth, but winging its way to the altitudes of human aspiration. We are victims all of the Oedipus fate and the emasculating dread called the castration complex. Our urges- hover between life and death; we are victims of birth traumas and sex shocks. Our genital origin imposes, a genital consciousness that never leaves us, and all we can do to live the life industrial, social, or intellectual is to con- vert and sublimate and transfer and symbolize dn'd project and rationalize arid idealize the original and persistent libido. Sex thou art, to sex returnest, was first (and last) spoken •of the soul. Is this really the truth of life? Is there no alternative except that of being glandular marionettes or Freudian fobots of most fear- ful and wonderful construction? Must we ever appease our “id”, consult our sub- and pre-conscious, make terms with ego and super-ego, before we can hope to understand ourselves or meet our' fellow men? Is a nor- mal man realty made in the image of a Freu- dian neurosis? Will the momentous decision of the future be Freud or anti-Freud? When we are told that the fear of small Tying or crawling insects derives from the tear of the father who also makes a sudden appearance and excites the idea of getting rid of him; that smoking derives from a fixation on the nipple, and eating sweets from the mother’s milk; that “later interests in paint- ing, sculpture, cooking, metal molding, and carpentry are believed to be traceable to cop- fophilic pleasure in smearing and molding” ; that characters . divide according to anal and oral persistences, we seem to be justified in consigning the entire system that sponsors such conclusions to the nearest wastepipe, and then ask wherein “psyching” is more scientific than other pretentious and marketable sys- tems of reading character. For there is the crux of the Freudian con- troversy. Viewed in one aspect it seems to offer a penetrating illumination into the motives of life; viewed in another, it becomes a gro- tesque and degrading caricature. What is wrong : the structure or the details, the archi- tecture or the plans and specifications ? Im- portant as it is to see the movement through, will the verdict of science declare it all in- genious futility and error, or a revelation of an unpleasant but vdrolesome truth? The re- flection can hardly be avoided: if this is Freud, is Freud -worth it? Dr. Healv has furnished the protocol for a fair trial, and has done so in terms of Freud’s, matures! convictions. Among the recent contributions of Freud is a temperate but definite essay, “The Future of an Illusion", describing the fate of religion as it emerges from the psycho-analytic mill. Will some future critic consider Freudianism under the same title? Medical Ethics LOWERING OF THE STANDARD OF ETHICS ]ohn Hammond Bradshaw, M.D., F.A.C.S., Orange, New Jersey “We have, lived from the time when public ad- vertising of doctors was considered an ethical sin; and into the time when the most , flagrant adver- tising of very prominent doctors in the lay press has been considered a remarkably virtuous per- formance.”— Parker Syms. I quote the above rather ironic words of a celebrated surgeon, the son of a most cele- brated father, which were recently received in a personal communication, and I give the pass- age with the kind permission of the author. Now, allowing for all altered conditions of this changing world, is the profession advanc- ing or retreating? The standard of so many things is under- going transition. Doctors are not the only ones on whom the spot-light can be thrown. Many of the practices of the present day, when viewed by the light of years ago, might not only bring ostracism to the perpetrators thereof,, but could even land these individuals behind bars. (But, ialas, the bars of those days were different from the bars of today!) Even the Church is having the spot-light of criticism thrown in its direction.. And this is not entirely the fault of the laity! 54 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Business by its very nature and require- ments is always changing its standards. An optimist naturally thinks things are always like Cone's little rhyme. Unfortunately, the other persuasions are vocal. If the writer should begin to write on the ethics of sex relationship, he might get him- self in deep waters, but here there are also many shallows — also many rocks! It is even a debatable question if the lower- ing of the present strict ethical standard of National Prohibition would not elevate the righteous cause of Temperance (spelled, with intent, with a big T). After all, “to err is human’’ ! A straight thinker is, generally speaking, also a “straight shooter”. What is the matter with the Golden Rule? Esthetics MUSIC IN RELATION TO ART AND LIFE PADEREWSKI’S PESSIMISM (From the Literary Digest, Nov. 15, 1930.) Paderewski sat on the edge of his chair as if playing the piano. The great shock of auburn hair, made famous in Burne-Jones’ drawing, is now thin and silvered. “His high but sloping forehead is his most characteristic feature, and, dome-like, it dominates the remainder of his head, and in comparison with the lower part of his face seems small.” “There is nothing of the far-away musician about him.” These bits of personal character, observed by S. J. Woolf, during his interview with Paderewski for the New York World, com- port with the thoughtfulness and vigor of the musician’s talk about the situation where our mechanistic age has placed all the arts, not simply music. Finding music is only a little behind the trend followed by pictorial art, he asserts that “art has been on an orgy”. Thus: Some few years ago it went wild for color. Line was forgotten in mad desire for vivid hues. Today music is still in the state that painting was in some years back. Color is the god before which all modern com- posers are worshiping, but they forget there are other gods than that. They have blinded their eyes, if I may so express it, to the beauty of the simple lines of the classicist, and endeavor by ef- fects of color to attain beauty without line. Light and shadow and the glow of color are wonderful, but they must have outlines to bound them, otherwise they are formless masses. And then, too, while I have been speaking of painting and music in similar terms, after all color is not music. Next he was asked what he thought was back of these tendencies in the arts, and Pad- erewski, who was once Premier of Poland, showed he has reverted to the artist, when he said : We are living in a strange age. Economics and inventions and discoveries have held the public attention for some years. I do not underestimate the value of these things. They, may make for physical comforts, but with them they bring attendant evils that kill creative genius in art. For genius is a tender plant which will not thrive in all soils or surroundings, and the quiet and peace that are essential to it have been driven out by the mad haste and constant desire for change and challenge that mark this era. Individuality and originality are being killed by the increasing necessity, I might almost call it, for collectivism. The day of the lonely craftsman has passed. One man rarely produces any finished product today. It is the result of many hands, and while better automobiles may perhaps be produced in this way, surely better poems or paintings or sonatas can not. And it is this spirit which is pervading everything. For great art, though it is the creation of one man, is the product and the result of the time in which he lives. Bach could not have written his works in a sky-scrapper any more than Michelangelo could have decorated one of the modern temples of in- dustry. Men are not happy today, he thinks, and, throughout the world, in politics as well as in all the arts, is “a constant desire to get away from existing conditions". He continues: In art there is a striving for originality. Men are endeavoring to create something new. Nothing new was ever created consciously. True originality has its foundations in the soul, not in the mind, and when there is an effort to create something different, it is usually a failure. Beetho- ven or Schumann or Chopin did not try to be original. They were original. However, this craving for originality, this desire to get away from old forms, this pulling down of the old-time gods, is typical of this period of the world’s history. Men feel the same dissatisfaction in regard to politics. Throughout the world there is an undercurrent of unrest. For years the so-called parliamentary system in government had been looked upon as a panacea for all ills. It was felt that when the man in the street was represented in a legislative body, then that man had something to do with the making of the laws and management of his country. But ideas in regard to this are changing. People are beginning to feel that this system is not altogether what it promised. Indeed, it has been my experience that in most bodies of this kind a tremendous amount of time is wasted in useless and futile talk. Jan., 1931 55 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Hours are used up in listening' to speeches of no import or value. In times of economic distress long discussions in parliaments only irritate. A hungry man’s appetite is not appeased by words. What he wants is food. And when he sees that the words do not give him food, he be- comes dissatisfied with that system of represen- tation which does not provide him with necessities, let alone comforts. It is this spirit of dissatisfaction with things as they are that has caused both the artistic and political restlessness throughout the world today. In Lighter Vein Fact-Finding Stuff A committee of 5 usually consists of the man who does the work, 3 others to pat him on the back, and 1 to bring in a minority report. — Royal Arcanum Bulletin. Banking On Wiley’s Nerves Jinks — “My wife thought she heard burglars last night, and I went straight downstairs to in- vestigate.” Binks — “Gosh, how could you be so positive she was mistaken?” — Chicago News. On the Sunny Side of the Grass “My brother is working with 5000 men under him.” “Where?” “Mowing lawns in a cemetery.” — Log. Concern advertises the perfect bridge lamp. Must be light enough to see by and too heavy to throw. — Dallas News. Scientists have achieved some wonderful re- sults, and maybe in time one of them will succeed in producing a cigarette the ashes of which will match the color of the rug. — Louisville Times. Answered at Last She (in poetic mood) — “What are the wild waves saying?” He — “Sounds like ’splash.’ ” — Panther. It now appears that the coffee situation is the chief cause for the revolution in Brazil. We’ve tasted coffee like that, too. — Judge. An insane-hospital up in New Jersey has in- stalled a miniature golf course for use of its pa- tients. Try to laugh that off. — Jackson News. As Good as a Lip-stick Martha, aged 4%, had been ill. Protruding her tongue, she asked : “Mother, how does my tongue look?” “Oh, it’s all coated white.” “You buy me a red lollypop and I’ll fix it.” In Dire Need of Strength The following message, pencilled on a scrap of wrapping paper, was recently delivered to a physician, member of this society: “Pleas give this boy strong medcin as I didn’t adminstrate reglar for 2 months so send some- thing strong.” Lighthouse Observations THE PUBLIC RELATIONS COMMITTEE It has been our custom to carry in this de- partment a resum.6 of recent scientific develop- ments in regard to some particular disease prob- lem but this month we are devoting the space to a problem of equally great concern to the profes- sion: i.e., to the best means of dealing with some problems that affect the health of the medical profession itself. At the moment there is so much discussion of economic problems, general and spe- cific, that we cannot find sufficient space for publi- cation of all that seems pertinent to our needs or relevant to our daily occupations. In consequence, we shall present for your information, through use of this column, an, abstract of views expressed at- the recent annual Conference of State Society Secre- taries and Editors, held under the auspices of the American Medical Association, by Dr. William H. Ross, President of the Medical Society of New York State. The meeting in Chicago this year, attended by the President of the Medical Society of New Jersey, Dr. George N. J. Sommer, as well as by your Secretary and Editor, Drs. Morrison and Reik, was an exceptionally interesting event; as you may learn from a special letter in this issue of the Journal, wherein President Sommer records his impressions. At each of these annual meetings, the Secre- taries of all the State Medical Societies — and such officers are in closer touch with and make per- haps the best possible representatives of gener- alized state professional opinion— confer upon one ‘ or more vitally important organization problems. On the recent occasion. Dr. Ross presented an elaborate paper upon the subject of “The Public Relations Committee” as developed in the medical society of his state during the past 3 years. We may be permitted to say at this point that the functions of that committee are embraced, in New Jersey, in the program of our Welfare Commit- tee; in other words, we have the same thing un- der a different name. In New Jersey, too, during the last 2 years, practically every county medical society has provided for a local welfare, or public relations, committee of its own, to function locally and to cooperate with the similar state society committee. So, we have, already set up, the ma- chinery for consideration of and action upon such problems as Dr. Ross , was discussing. Dr. Ross’ paper will in due time be published in full in the American Medical Association Bulletin, so we shall attempt here to present only a con- densed report upon the more important features of his address, as follows: There is an economic disturbance in the medical profession greater even than the general economic disturbance in industry. The medical profession has for some time blamed health organizations, and even departments of government, for public health activities, on the ground that they have in- terfered with the private practice of medicine. The profession has seemed to believe that inter- ference with private practice is solely due to ac- tivities of these agencies, and has seemed to for- get that medical research and discoveries, to- gether with changed social conditions and in- crease in public knowledge, are the real causes of such activities. Times are changing. The gen- eral public, has become interested, and industry and civic organizations are at work, in response to public demand and supported by public opinion, trying to advance health service with a view to 56 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., J931 saving as much as possible of the $100,000,000 an- nual wastage through preventable illness. There is an oncoming tide of public sentiment for the advancement of public health, with the object of limiting illness and lengthening life, and providing adequate medical care in sickness;-. No one could sit through , the recent. 4-day meeting of the Ameri- can Public Health Association, with its 10 sections going on concurrently, its 16S speakers listed, and the largest number of practicing physicians ever in attendance, without realizing that times are indeed . changing. The effort of organized medicine to meet its own professional problems has up to The present time been along , the line of creating committees and bureaus for study of economic problems and in argument against the health ef- forts of various agencies and the paternalistic tendencies of government. Organized medicine has not undertaken an impartial appraisal of its own organization to see whether its own public medical relationships are such as to make it most efficient in the distribution of preventive measures and provision for medical care. . Organized medicine must realize that the day of isolation is over and that it must go through the throes of adjustment to new conditions and prepare to go along with the irresistible force of public opinion. Our Public Relations Committee in 'New York has during the1 past 2 years ar- rived at a more comprehensive conception of . the obligations resting upon the medical profession — to render satisfactory public service as well as to attend to its own private business. We recognize that scientific medicine has develojied much faster and traveled further than has the application of scientific discoveries to the limiting of unnecessary illness and the provision for adequate care of all classes of sick people. This committee believes that it, is, proper to secure aid from other sources, when funds are not available from general taxation, for administrative organization of mass or semi-mass health service, and for health education; that the profession is responsible for guidance of all efforts to advance preventive medicine; and that the pro-, fession should be the major factor in proposals for solution of the great problem of adequate medi- cal care. Organized medicine will not overcome its diffi- culties until it has made a proper self-appraisal and determined whether it is meeting all of its obligations to render public service. If it does not meet these obligations, some other agency will; and possibly in a manner that will be unsatisfac- tory to the profession. The organized profession of Great Britain has just made a proposal for ex- tension of the National Health Insurance Act; a proposal that might better have been made 20 years ago, although it is to the credit of the Brit- ish Medical Association that it is now properly meeting the situation. There is a lesson in this for the medical profession of America. Will we heecl it? Medicine has come to have a public character ; knowledge of what can be had in the way of health service is rapidly expanding; the broad- casting of unsolved health and medical problems is increasing. The social trends of the time ir- resistibly insist upon better health service; as is reflected in public welfare laws, old age pensions, etc. The profession is confronted by a new state of affairs. Heretofore, medicine lias spent its effort largely in studying the effects of public health service upon its own material rewards and has given a minimum of consideration to the causes under- lying social changes. We might well consider some of these social changes: the increased pur- chasing power of the public, due to better wages- and shorter hours of labor; increased education; tripling of the per capita wealth during the past 25 years; the increase in man productivity by 40% within 12 years; the present mechanized state of,, industry, resulting in unemployment because of the lessened need for men. Emerson tells us that society is always taken by surprise at any new example of common sense. Let us see if we can apply common sense to our problems. There are 2 methods of procedure open to the medical profession. One is to fight public opinion and retreat as slowly as we can; you can find examples of that expressed quite fre- quently in medical meetings. The other is to ac- cept the practical philosophy of self-appraisal, and if the result of such self-examination warrants it, to make proposals for meeting public health needs by the prevention of illness and the jn’ovision for proper care of the people when sickness combs. The second method may be successfully followed if our relationships be changed so as to cooperate with other agencies under the expert guidance of the medical profession. Are we equal to this responsibility? The Public Relations Committee of the- New York State Society, as a preliminary step, under- took to have organized in every county society a Public Relations Committee. Then, it undertook to have each county committee make a survey of the health activities of the county and the relation of the local profession to them. If the principle of conference between the various health agencies was not in use in reaching conclusions, and if there was not a cooperative relationship, then the State Committee undertook to bring about such a conference with the object of cooperation on the fundamental basis that the medical profession was the only body that could give expert guidance to methods of distribution of health services and that it was willing to be consulted. Notwithstanding the almost complete transfor- mation of medicine within the recollection of many of us, because of laboratory aids and the use of instruments of precision in diagnosis and treat- ment. there may come another revolution in medi- cal practice, as it has come in the past, as the re- sult of great social needs, and who knows that it is not beginning. We may be nearer than we know to such things as unlimited old age pensions, provision for adequate medical care by the state, and the inclusion of sickness benefit in Workmen’s Compensation and compulsory health insurance laws as in other countries. It should make us think. The work that the Public Relations Committee undertakes to do is to establish by conference a conclusion as to plan and then a cooperative re- lationship between official and unofficial health agencies and the medical profession. It under- takes to arouse medical interest in present day social trends and the need of providing plans for the distribution of preventive service, i. e. the establishment of a county health department with a full-time and trained personnel. Another is the support of the work of Parent-Teacher Associa- tions and the value of the family physician in pre- school work. Another is the proper relation of the medical profession to the movement on the part of the state to aid in the establishment of county hospitals so that the entire profession may have the educational opportunity arising from service in a hospital and in formulating rules and regu- lations to control standards of practice. The Public Relations Committee undertakes to Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 57 adjust differences of opinion between the medical profession and the health activities of other or- ganizations by use of the principle of conference while the proposals are in the formative stage. It undertakes to visualize the medical future; to see as far as possible what is ahead in medicine and plan such relationships as are necessary for medi- cal leadership. The medical profession can never cure the ills that it complains of by fighting the present social trends. It can no longer afford, in more senses than one, to hold a hostile attitude to- ward any health agency supported by public opinion. It will suffer if it does not have a re- ceptive rather than a hostile attitude. I have been a part of a movement in my county medical society that has resulted in as desirable a relationship of the profession and health agencies as one could conceive of — a movement that has given the profession leadership with the support of lay organizations. A county medical society that does not modernize its relationship into har- mony wtih new conditions is not meeting its pro- fessional obligations nor laying a foundation to prevent economic disturbance of the private prac- tice of medicine. No amount of resistance to the present social trends will make any final difference. Continuation of present methods to cure our ills will amount to nothing. To consider medicine under seige, and the tendencies of government as paternalistic, will avail nothing; but self-appraisal of ourselves and proposals from the organized profession regarding medical problems will succeed and will put the profession of medicine in the position that it should be in and the position that public opinion expects it to occupy. Public Relations SURGEONS REDUCE FEES (From N. Y. Times, Nov. 18, 1930.) A plan to reduce the cost of medical attention for the so-called white-collar workers, under which 2 hospitals will reduce their rates and prominent physicians and surgeons will give their services at decreased 'fees, was announced last night at a dinner in the Hotel Commodore. The hospitals are the Park West at 170 West Seventy-sixth Street and the Park East at Park Avenue and Eighty-third Street, both built origin- ally by the same stock company to care for wealthy patients. The plan was described to 200 members of the staff of the 2 institutions by Thomas F. Dawkins, executive manager of both hospitals. If the reduced rate program proves successful, both institutions will be turned over to the doctors and nurses of their staffs for operation as co- operative enterprises, according to Mr. Dawkins. Although the plan was not announced as in any way connected with the recent statements of Health Commissioner Wynne, that doctors are faced with the alternatives of lower fees or State Medicine, it agrees with Dr. Wynne in its em- phasis on the need for placing hospital care with- in reach of persons with moderate incomes. The Park West Hospital, opened in 1926, has 75 beds and represents an investment of $750,000. The Park East Hospital has 130 beds. It was opened in September 1928, at a cost of approxi- mately $1,000,000. Since these institutions were designed at first only to serve wealthy patients, the cost for a room was fixed at from $13 to $40 a day, Mr. Dawkins said. Under the new plan it will be pos- sible to obtain a room for $6.50 a day. For those who desire better accommodations there will be a maximum of $30 a day. The practitioners who have already agreed to reduce their fees include some of the best known medical men in the city. The practice of basing fees for operations on the patient’s apparent ability to pay would be curtailed to a great extent, Mr. Dawkins indicated. Medical men connected with these institutions include Dr. Thomas Darlington, former health commissioner, who is on the advisory board, and Dr. Howard M. Hayes, president of the board of both institutions. INFANT MORTALITY LOWEST IN HISTORY (Newark Evening News, Oct. 24, 1930.) New Jersey’s infant mortality rate for 1929 is the lowest ever recorded for this state, according to statistics of the bureau of census and division of vital statistics of the United States Department of Commerce. The rate was 60 deaths under 1 year of age per 1000 births. New Jersey is 1 of 11 states whose rates are lower than at any time since their admission to the registration area. The infant mortality rate throughout the regis- tered area, which comprises 46 states and the Dis- trict of Columbia, is 68 per 1000, the second lowest since the establishment of the birth registration area in 1915. For the sixth consecutive year, Ore- gon leads the states with the lowest rate, 48. While the infant mortality rate throughout the country was lower than usual last year, statistics show that the birth rate for 1929 was 18.9, the lowest for any year since establishment of the birth registration area. Oregon had the lowest rate, 14.1, of any state. New Jersey’s rate was 17.2. PENDING LEGISLATION ON ABELL COMMISSION REPORT In the Welfare Committee Minutes (page 65) you will find a review of the 3 Bills now under consideration in the Senate of the General Assem- bly, and will note the decision to oppose passage of those Acts. It seemed necessary to oppose S. 262 and S. 304 in toto because of their glaring defects. Inasmuch as the medical profession is not opposed to a proper budget system honestly constructed and applied alike to all governmental departments and boards, without discrimination, it was suggested that these Bills could be made acceptable by amendment, and the changes pro- posed were designed: to clarify the question of authority; to guarantee that the boards would be allowed appropriations as large at least as their own receipts — to carry on law enforcement; to place the new “bureau” under the Board of Regents instead of a state officer whose appoint- ment and tenure of office are subject to political control; and, to “cover in” the lawyers and realtors along with other examining and licensing boards. These points are all excellently well expressed and approved by an editorial in the Camden Courier-Post of December 16, as follows: Bill 304 Carries the Spirit of Reform but not the Substance! New Jersey has 14 separate professional boards. Each has its own secretary, maintains its own in- specting staff, operates its own office and collects and disburses its own funds. 58 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Bill 304, sponsored by the Abell Commission, would consolidate 12 of these boards under a Bureau of Professional Registration. Hearing on that measure takes place today, and vigorous pro- tests are being lodged against it, especially by the medical profession. The principle embodied in this bill is one for which this newspaper has long stood — economy in state administration through consolidation of ac- tivities and centralized financing. No private business permits each of its departments to handle its own financial affairs and, to all effects, operate as an independent concern. There are, however, serious defects in Bill 304. The medical profession, not without reason, asks why the legal profession should be exempted from the measure along with the State Real Estate Board? If it is good business to consolidate 12 of the 14 State boards should it not be even better business to consolidate the whole 14? Lawyers, however, drew up the measure. And by exempting themselves they expressed exactly the same opposition to the bill that the physicians and other protesters are to make at today’s hear- ing. That is, they don’t object to the principle of this bill — only they don’t want to be subject to it. ****** More serious than that seeming discrimination, however, is the fact that Bill 304 will tend to limit the professional authority of the various boards, although they will still be continued in existence. There is a justification for the fears of physi- cians that the proposal to place all the boards under the authority of the Commissioner of Edu- cation— a political appointee — will tend to bring politics into the various boards and lower their standards. Especially is this important where the boards concerned are charged with safeguarding the pub- lic health. Most important of all, in the medical profession! New Jersey has high standards which should be maintained free from political influence. Bill 304 does not guarantee that, even though the Abell report clearly states “the regulatory work of these boards would in no manner be interfered with.” Moreover, the purposes of the scheme as out- lined in the Abell report do not seem fully real- ized in the proposed legislation. In the report it is stated: “We recommend that a Bureau of Profes- sional Registration be created in the Depart ~ ment of Education which will consolidate these twelve examining and licensing boards into one unit, with one Secretary instead of the dozen now drawing pay. Great economies in rents would likewise be effected.” But the bill itself reads: “The Commissioner of Education shall . . . appoint a secretary of said bureau and such clerical, technical and other assistants as may be necessary, fix their compensation and pre- scribe their duties . . In short, while there will be one secretary, there xoill be a lot of other jobs, under other names. Insofar as Bill 304 covers the consolidation of the financial functions of these professional boards it has our hearty approval. But we do believe the measure is weak in that it is not emphatic enough in assuring the public that their regulatory functions will not be mo- lested; and that it is far too vague as to how the promised economies in operation are to be effected. In brief the measure should be redrafted along these 3 lines: To consolidate the boards in matters of finance; To preserve their standards of qualification, notably in the professions which concern the pub- lic health; And lastly, to make definite, in the bill itself, a guarantee that there will be real economy and not sham economy! THE WHITE HOUSE CONFERENCE ON CHILD HEALTH AND PROTECTION Reported by William G. Schauffler, M.D., Princeton, N. J. The Conference on Child Health and Protection called by President Hoover met in Washington, D. C., on November 19, 1930, and continued through November 22. The sessions were held in the group of buildings centering around the Red Cross Build- ing and the Hall of the Daughters of the American Revolution. Conference headquarters was at the Interior Department Building, and the general meetings were held in Constitution Hall, which holds about 5000 people, and which was filled at the opening session on Wednesday evening, when President Hoover made the opening address after Secretary Ray Lyman Wilbur, M. D., Chairman of the Conference, had welcomed the delegates. Over 3000 delegates attended this meeting, com- ing from more than 20 states. They represented the tremendous interest shown in all parts of our country for, child welfare, and were a remarkably fine body of men and women. The work of the conference was divided into 4 Sections as follows: Section 1. Medical Service, subdivided into (a) Growth and Development. (b) Prenatal and Maternal Care. (c) Medical Care for Children. Section 2. Public Health Service and Adminis- tration. (a) Public Health Organization. (b) Communicable Disease Control. (c) Milk Production and Control. Section 3. Education and Training. (a) The Family and Parent Education. (b) The Infant and Pre-School Child. (c) The School Child. (d) Vocational Guidance and Child Labor. (e) Recreation and Physical Education. (f y Special Classes. (g) Growth Outside of Home and School. Section 4. The Handicapped. (a) State and Local Organizations for the Handicapped. (b) Physically and Mentally Handicapped. (c) Socially Handicapped, Dependency and Neglect. (d) Socially Handicapped, Delinquency. In preparation for this conference more than 150 committees and subcommittees had been gath- ering material and collating it for consideration during the past year, and the facts were stated in a most intelligent and comprehensible manner. Breakfast, luncheon and dinner groups were held during the 3 days of the meetings, at which the subjects could be talked over more informally than in large group meetings. On Saturday morning the 4 Section chairmen presented consolidated reports, and the conference was concluded with the “Consideration of Reports Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 59 by the Conference”, presented by the Chairman- Secretary Hon. Ray Lyman Wilbur, M. D. These conclusions, which will form the basis of work in all parts of the country, were as fol- lows: Every American child has the right to the following services in its development and protec- tion. Every child should he understood. (1) Every prospective mother should have suit- able information, medical ■supervision during the prenatal period, competent care at confinement. Every mother should have postnatal medical super- vision for herself and child. (2) Every child should receive periodic health •examinations before and during the school period, including adolescense, by the family physician, or the school or other public physician, and such ex- amination by specialists and such hospital care as its special needs may require. (3) Every child should have regular dental ex- amination and care. (4) Every child should have instruction in the school in health and in safety from accidents, and every teacher should be trained in health programs. (5) Every child should be protected from com- municable diseases to which he might be exposed at home, in school or at play, and protected from impure milk and food. (6) Every child should have proper sleeping rooms, diet, hours of sleep and play, and parents should receive expert information as to the needs of children of various ages as to these questions. (7) Every child should attend a school which has proper seating, lighting, ventilation and sani- tation. For younger children, kindergartens and nursery schools should be provided to supplement home care. (8) The school should be so organized as to discover and develop the special abilities of each child, and should assist in vocational guidance; for children, like men, succeed by the use of their strongest qualities and special interest. (9) Every child should have some form of re- ligious, moral and character training. (10) Every child has a right to a place to play, with adequate facilities therefor. (11) With the expanding domain of the com- munity’s responsibilities for children, there should be proper provision for and supervision of re- creation and entertainment (12) Every child should be protected against labor that stunts growth, either physical or men- tal, that limits education, that deprives children of the right of comradeship, of joy and play. (13) Every child who is blind, deaf, crippled or otherwise' physically handicapped should be given expert study and corrective treatment where there is a possibility of relief, and appropriate develop- ment or training. Children with subnormal or ab- normal mental conditions should receive adequate study, protection, training and care. (14) Every waif and orphan in need must be supported. (15) Every child is entitled to the feeling that he has a home. The extension of services in the community should supplement and not supplant parents. (16) Children who habitually fail to meet nor- mal standards of human behavior should be pro- vided special care under guidance of the school, the community health or welfare center, or other agency for continued supervision, or, if necessary, control. (17) Where the child does not have these ser- vices, due to inadequate income of the family, then such services must be provided for him by the community. (18) The rural child should have as satisfac- tory schooling, health protection and welfare facilities as the city child. (19) In order that these minimum protections of the health and welfare of children may be every- where available, there should be a district, county or community organization for health, education and welfare, with full-time officials coordinating with a state-wide program which will be respon- sive to a nation-wide service of general informa- tion, statistics and scientific research. This should include: (a) Trained, full-time public health officials with public health nurses, sanitary inspection and laboratory workers. (b) Available hospital beds. (c) Full-time public welfare services for the relief and aid of children in special need from poverty or misfortune, for the protection of chil- dren from abuse, neglect, exploitation or moral hazard. (d) The development of voluntary organizations for children, for purposes of instruction, health and recreation through private effort and benefaction. When possible existing agencies should be co- ordinated, to avoid overlapping. It is the purpose of this Conference to establish the standards by which the efficiency of such services may be tested in the community, and to develop the creation of such services. These standards are defined in many particulars in the reports of the committees of the conference. The Conference recommends that the continuing committee, to be appointed by the President from the conference, shall study points upon which agreement has not been reached, shall develop further standards, shall encourage the establishment of services for children, and re- port to the members of the Congress through the President. New Jersey was well represented at the Con- ference by members of the State Medical Society and laymen and women. Commissioner William J. Ellis, of the Department of Institutions and Agen- cies, was prominent in the work of Section 4. State Health Department STATE HEALTH LAWS (A communication from D. C. Bowen, Director New Jersey State Department of Health.) Wide commendation is meeting the ‘‘Physicians’ Handbook”, prepared and distributed by the State Department of Health. Simplicity and conciseness of the new booklet of vest-pocket size for handy reference are the characterizations of one of its en- dorsers. Copies are available to physicians of the state without cost and may be obtained by com- municating with the department, at the State House, Trenton. Do you find it hard to keep in mind just what matters you should report to boards of health and when and how these reports should be made? It is not surprising if you do. Regulations on the subject are long and appear in several different laws which are not easy to read nor to remember. The Physicians’ Handbook lists under separate headings subjects on which you are expected to re- port, in accordance with various laws and regu- lations, state-wide in effect. The booklet is ar- ranged in a manner convenient for ready refer- 60 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 ence. Legal terms are avoided. It is concise, and I believe it will be helpful to you. Will you not look over the booklet now and note what it con- tains. It will fit your pocket. Acknowledgements have been most gratifying to the department for the work involved. Dr. James J. McGuire, of Trenton, Secretary of the State Board of Medical Examiners, plans to give each successful candidate qualifying in the board’s examinations a copy of the booklet, which the State Department of Health will supply. The reportable communicable diseases, dog bites of persons, epilepsy and mental deficiency, and drug addicts under treatment are dealt with under a uniform arrangement of sub-heads which in- clude: (1) what diseases to report, (2) what facts to report, (3) to whom to report, and (4) when and how to report. Reporting of diseases ' which occur on dairy premises, and of venereal diseases, is discussed under appropriate headings. Physicians’ duties with respect to recording births and deaths are explained in a concise way. The busy physcian will find in the 12 pages of this booklet information he frequently needs in a form convenient for ready refei-ence. In a foreword to the booklet, the department said : Physicians are usually the first who see cases of communicable diseases in a community and are able to give authoritative warning of their presence. Local health departments have been empowered to enforce measures to prevent the spread of these diseases, but no health department, however well organized, can plan nor apply effective measures to prevent their spread without a knowledge of when and where cases occur. Responsibility has also been placed upon health departments to collect records of births and deaths, and to preserve these records, so important to the people of the state. Again it is the physician who has knowledge of facts and conditions essential to such records. For the public welfare, therefore, state laws and regulations have placed upon physicians the duty of reporting cases of communicable diseases and certain other ailments, and of filing or supplying facts for certificates of births and deaths. A digest of these state-wide, legal requirements, for the reference of physicians, is given in this booklet. Communications IMPRESSIONS OF THE ANNUAL CONFER- ENCE OF SECRETARIES OF CONSTITU- ENT STATE MEDICAL ASSOCIA- TIONS, 1930 Dr. George N. J. Sommer, M.D., Trenton, N. J. This meeting was held at the American Medi- cal Association Headquarters in Chicago, Novem- ber 14-15, 1930. On the invitation of Drs. Mor- rison and Reik, I attended this meeting and was cordially received by the President, Dr. William Gerry Morgan, Secretary Olin West, and various members of the Board of Trustees, one of whom, Dr. J. H. J. Upham, of Ohio, happened to be an old class-mate. The papers presented were quite notable and quite to the point, dealing largely with present day problems of the profession in its relations with the general public. The paper of Dr. R. L. Parker, of Des Moines, on “Service for the Indigent Through Contract with the County Medical Society’’, described a plan which has been put into practice by 11 of the county societies in Iowa and apparently is working out satisfactorily. A close study of this plan would solve this problem to the satisfaction of physicians and public in rural counties at least. (See editorial, this issue.) Dr. F. C. Warnshuis, of Grand Rapids, Michi- gan, read a paper on “The Relations of State Boards of Medical Examiners to State Medical Associations”; which seemed to be similar to what we have in New Jersey, but which ar- rangement for us seems to be in grave danger from the Abell Report recommendations. Dr. W. C. Rappelye spoke on the general sub- ject of “Health Insurance’’ and gave some facts relating to the systems in vogue in England, Germany and other countries of Europe. No solution for our country was advanced but the data gathered by him will need to be considered by us to solve our problem in this regard. “Co- operation Between Medical, Public Health and Educational Organizations” was discussed by Dr. E. A. Myerding, of St. Paul, in a lengthy descrip- tion of the method now in use in Minnesota. It is an expensive, thorough program financed by the State Medical Society and Social Service Or- ganizations, under one head, and is working well; an example of a good way to do a necessary work under control, as it should be, of medical men. Dr. F. C. Hammond, of Philadelphia, Editor of the official organ of the Pennsylvania State Medi- cal Society, presented his ideas on “What a State Medical Society Journal Should Mean to the So- ciety Membership”. This paper will bear inten- sive study by medical men of any state. Our Journal measures up to all of the standards he established and is serving our membership ex- ceptionally well. The last, but not least, was a paper by Dr. William H. Ross, President of the State Society of New York, on “The Public Relations Com- mittee”. This is the coming bulwark of the pro- fession against the encroachments of State Medi- cine and the problem was discussed in scholarly manner by one who has given much of life and time to study of professional relations with the public. No doubt this paper will have a great influence on this perplexing problem and its solution. After hearing all these papers on.' was struck with the grasp of the various authors on the great problems of the profession of our times, and no doubt the papers will be of use to us in New Jersey in solving our own problems. I was personally much impressed with the re- markable executive talents of Drs. Olin West, Secretary, and Morris Fishbein, Editor, in their sane attitudes toward the problems which confront the medical profession. MENTAL HYGIENE (A letter from Dr. F. E. Williams, Medical Di- rector, National Committee for Mental Hygiene, New York City.) The phenomenally rapid growth of interest in all aspects of extramural psychiatry in recent years has created several situations of consider- able gravity, of which the shortage of adequate- ly trained personnel is by far the most pressing. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 61 The mounting interest of communities in child guidance and other types of mental hygiene clinics has already exhausted the never-suflicient supply of specially trained psychiatrists for this work, and unless physicians with the requisite training and aptitude can be secured in greater numbers, either the establishment of many new clinic projects will be delayed, or, worse, their functioning will be attempted by unprepared or poorly prepared staffs. To assist in lessening some of this shortage of properly trained psychiatrists The National Com- mittee for Mental Hygiene offers fellowships toward acquisition of the special preparation required. Details of these fellowships are con- tained in the enclosed announcement, a repro- duction of which in the columns of an early is- sue of your periodical will be deeply appre- ciated in the interests of modern medical edu- cation. Minimum Requirements for Applicants These fellowships are designed to provide spe- cial training for physicians who have had pre- vious hospital training in psychiatry but who wish to prepare themselves for extramural work in the fields of child guidance, delinquency, edu- cation, dependency, and industry. Fellowships are open to physicians who are: (1) Under 3 5 years of age. (2) Graduates of Class A medical schools. (3) Who have had at least 1 year of training in a hospital for mental disease maintaining sat- isfactory standards of clinical work and instruc- tion. A longer period of hospital training is de- sirable. Applicants able to meet these requirements will not be required to take competitive written or oral examinations. Selections will be made on the basis of length and type of previous train- ing in formal psychiatry; on general fitness for the work contemplated; and (in most cases) on the results of a personal interview. General Details of Fellowships (1) These fellowships cover a period of train- ing approximately 1 year in length. (2) During this training period, trainees usu- ally are assigned for 3 to 4 months’ periods at such places as the Boston Psychopathic Hos- pital; Judge Baker Foundation, Boston; Insti- tute for Juvenile Research, Chicago and other places of a similar nature, as well as to various child guidance clinics located in Cleveland, Phila- delphia and other cities. Assignments to these training centers are not definite, however, and as- signment to any given place will depend upon the availability of instruction at such place, as well as the special needs of the individual trainee. Assignments are not made for more than 3 months in advance, and adheience for the year’s training period to a fixed program in advance is impossible. (3) These fellowships carry stipends at the rate of $2000 to $2500 for the 12 months’ period. (4) Applications need not be filed within stated periods but will be received at any time. In the case of successful applicants, arrange- ments will be made to begin work whenever mutually convenient to the applicant and to the director of the training center to which the ap- plicant is first assigned. Applications or inquiries for further informa- tion should be sent to Dr. Frankwood E. Will- iams, Medical Director, National Committee for Mental Hygiene, 37 0 Seventh Avenue, New York, N. Y. PRE-SCHOOL AND SCHOOL PIIYSICAD EXAMINATIONS Harold Edwin Wright, M.D., Princeton, N. J. (A letter to the Journal, under date of Novem- ber 11, 1930) In the issue of the Journal for October 1930, under School Health Department, was an article entitled, “Preliminaries to the School Doctors Examination’’. It appears much like a harmless little article and hardly worth commenting upon but its prac- tical worth, while of little value should be dis- cussed. Some writers on questions relating to school matters always seem to think the teacher has plenty of spare time on her hands, and thoughtlessly suggest some new idea to consume some part of her day in helping to carry out some suggestion; very often a foolish one. After about 20 years experience as a school medical inspector, connected with a school sys- tem of very high standing, I feel I am compe- tent to express myself with some judgment of experience. Where can there be any improve- ment in the mental attitude of a. child who re- ceives a physical examination the first week of school or the third week? What can a teacher do to prepare a child to meet a school medical inspector, if the inspector does not understand how to meet and handle children? Also1, how does a child’s mental status improve a physical defect? If the examination consists of a psych- ologic laboratory test, then the mental prepara- tion could be appreciated, but the examination of eyes, throat, ears, posture, heart, lungs, etc., needs no mental preparation; such organs have either a defect or no defect, which is readily as- certained. A child to be examined physically in school is in a very different class from a child who approaches a physician for some ailment. Delaying the examination for a few weeks is a small matter, very true, but what have you ac- complished by such a delay? Observation in the class room by the teacher, to ascertain any peculiar traits of a child, such as likes, dislikes, habits, etc., will be of value pos- sibly to the teacher but not to the doctor. The efficient school inspector does not need assist- ance of the teacher to discover whether a child is undernourished. In comprehensive school sys- tems the children are weighed each month by the nurse and records are kept, which enables the school physician to bring influence to bear at home. While the duties of the nurse are multi- plying and her responsibilities are greater, yet she should always be at the disposal of the medi- cal inspector to assist him both in conducting physical examinations and follow-up work on detected defects. Just how much progress and thoroughness is made in other places, the writer does not know. However, we do feel that in Princeton every side of the question of school medical inspection is practiced. For many years we have been very particular concerning health of the teachers and a physical examination of each one is made an- nually. We are laying particular stress upon the pre-school examinations of children. These ex- 62 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 animations are only conducted in the presence of the parent. They are by far the most important examinations made. They enable the child to enter school with all defects corrected, and the parent of the child is taug-ht to appreciate the value of such corrections and how to care for a child that is not normally developed. In Prince- ton these examinations are conducted every spring and are becoming each year more popu- lar. Place the child in school with 100% physical condition and the teacher will have much less trouble with the mental development. To do this, we do not need any foolish training of a child’s mind to meet the doctor. Also, such ex- aminations of pre-school ages conducted in the presence of the parent can be done with the clothing removed. We sincerely hope the remov- al of all clothing of each school child, as has been suggested, will never be practiced. It would create, and justly, a storm of criticism, and in the opinion of the writer would require possibly 2 examiners, a man and a woman. This is unnecessary expense to the taxpayer for ques- tionable results. It is a procedure which is not required if pre-school age examinations are em- phasized. It is very hard for the writer to un- derstand why so great a weight is placed upon a foundation the strength of which has not been estimated. If we have knowledge of the child’s physical condition when it commences its school career, we know what to expect and what can be done. This view , certainly is a practical one; it is an inexpensive one; and it eliminates a great deal of the so-called gallery play or ideal- istic impracticabilities. The rural districts can afford thorough pre-school physical methods when they can see the results, but cannot afford the many useless methods advocated for the school child after it has entered upon its career. It seems strange that more common sense and not so much theory does not prevail. Another point that must be borne in mind is the difference in methods used in the larger com- munities and those used in the rural districts. It is very possible for the larger towns, where enrollment is very large, to practice what is be- ing done in New York; i.e. for the teachers in each grade to set aside 1 day for gross inspection of the pupils for enlarged tonsils, eye-readings, hearing tests, and detecting any unusual abnor- mality; I do not mention teeth because they should come under the dental department. This procedure may have its valuable side in places where thousands of pupils are to be examined, but it would not fulfill the law in New Jersey where it is specified that examinations must be made of each pupil, each year, by a medical in- spector. Should there be a change in the pres- ent system, the writer sincerely hopes it will be the development of a system in regard to the pre-school medical attention. Also, if a child enters school pronounced free from defects, an- nual physical examinations would be super- fluous. Examinations upon entrance to school and subsequent ones about the third and sixth years would cover the requirements. While the duties of the school nurse are in- creasing each year, so are the duties of the medical inspector. Communicable diseases re- quire his daily attention, and should never be diagnosed by any one except a physician. Con- trol of them requires close cooperation of the Health Officer of the community. Preventive methods now so widely used for immunization against these diseases requires much more time of the medical inspector. In addition to all this the medical inspector is at the disposal of the athletic de_partment for any injuries or opinion in matters pertaining to the medical side of that department. There is plenty for the nurse and doctor to do and do thoroughly without the ad- dition of questionable ideas. ABELL COMMISSION REPORT (A letter, advising caution with regard to legis- lative matters, from Dr. Elias J. Marsh, Treas- urer of the Medical Society of New Jersey.) I have received from the State Board of Medi- cal Examiners a copy of the proposed law to con- solidate the administrative work of various pro- fessional examining boards, together with notes on the experiences of other states where similar plans have been tried. From these it appears that the results have not been altogether satis- factory, and our Board seems to fear that the proposed plan would hinder them in some of the work they are now doing. S. 304 is one of a series of acts offered by the so-called Abell Commission for the general re- organization nad simplification of the state govern- ment. The great need 'of such a reorganization is generally recognized, and I think there is little question among our people that in its main lines the plan outlined by the Commission is wisely and soundly conceived. Perfection in all details is hardly to be expected in a work of this character, and opinions will differ; there are always minor defects which are subject to just criticism. Unfor- tunately, opposition, even when just in itself, on account of what are really minor points, im- portant though they may seem to those inter- ested, often strengthens the resistance to great and necessary reforms offered by interested per- sons for selfish reasons. It would be a great mis- fortune for the state, and a heavy charge against those responsible, if this great opportunity to re- form our government should be lost by the aid of objections raised against details, however valid the objections in themselves. I am not sufficiently familiar with the opera- tions of the Board of Medical Examiners to pass an opinion, but most of the mentioned difficulties appear to me incidental, and remediable by amendment, rather than inherent. But even granting them as serious as the members of the Board seem to regard them, we should remember that we are citizens before we are physicians, and the state is entitled to priority of consideration even before our profession — supposing there is any conflict, which I did not admit. After all, the work of the Board of Medical Examiners, like all other boards, is for the welfare of the people, not of the profession, and if the best advantage of the state demands some sacrifice on our part — mind, I say if — it ill becomes that profession which is justly proud of its self-sacrifice and pub- lic spirit to refuse it now. By all means let us strive for such changes in the bill as will con- serve the advantages for the public service en- joyed by the present board, without lessening the main puropse of the reform, but I sincerely trust that our Welfare Committee and the leaders of our society, as well as the members of the Board themselves, will not place the society and the pro- fession in the position of hindering in any way the most hopeful promise of civic reform seen in New Jersey in a generation. (Signed) — Elias J. Marsh. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 63 AMERICAN PHYSIOTHERAPY ASSOCIATION (A letter transmitted to us by Dr. Harold D. Corbusier, with approval for publication.) The New Jersey Chapter of the American Phy- siotherapy Association, a national association of physical therapy technicians organized shortly after the war, has established a registry and ap- pointment bureau for its members in this state. Requirements for membership in this associa- tion are as follows and are approved by the Council on Physical Therapy of the American Medical Association. Active members are those having had 1 year of practice in physical therapy within 2 years of graduation from: (1) An approved School of Physical Therapy. (2) An approved School of Physical Education and satisfactory completion of an approved course of physical therapy. (3) An approved School of Nursing and satis- factory completion of an approved course of physical therapy. Junior members shall be persons fulfilling the requirements of active members, except 1 year of practice shall not be necessary; nor shall they have the power to vote. The standards of ethics of the American Phy- siotherapy Association shall be as far as possible those of the American Medical Association. All members shall practice only under the prescription and direction of a licensed physician. . Therefore, only persons having the best possible training may register in this bureau. It is the place to which the physicians may apply when in need of well trained physical therapy technicians either in their private offices or in hospitals. The registry is under the direction of Miss Jean Smith, Beth Israel Hospital, Lyons Avenue, Newark, N. J. Telephone — Terrace 3-5700. VIOLATIONS OF MEDICAL PRACTICE ACT (A letter from Dr. J. J. McGuire, Secretary of the State Board of Medical Examiners.) Schuyler C. Pew, of Perth Amboy, was found guilty of practicing medicine without a license, on September 8, by the Judge of the New Bruns- wick District Court. Mr. Pew held himself out as a masseur and also gave electric treatments. Theodore DeDragic, of Atlantic City, who held himself out as a Vienna physician and physio- therapist, was found guilty of practicing medicine without a license on September 10, and on failure to pay the penalty was committed to jail for 30 days. Emma L. Garwood, of Beverly, who advertised as a masseuse and electrotherapist, pleaded guilty in the Court of Common Pleas of Burlington Coun- ty, on September 11, to a charge of practicing medicine without a license. Frank Weber, of Burlington, pleaded guilty in the Court of Common Pleas, of Burlington Coun- ty, on September 11, to a charge of practicing medicine without a license. Mary A. Wilson, a psycho-analysist, of Newark, on September 18, paid the penalty for practicing medicine without a license. Thomas Parusis, of Jersey City was found guilty in the First District Court of Jersey City, of prac- ticing medicine without a license. On failure to pay the penalty, he was committed to jail for 30 days. Daniel S. Priest, druggist, of Toms River, in September 1930 paid the penalty for practicing medicine without a license. Ernest M. Bick, of South Orange, who pre- scribed medicine to be taken internally, was tried in the Second District Court, Newark, on Octo- ber 3, on a charge of practicing medicine without a license, and was convicted. He had previously been convicted on January 28. Lillian Kallila, of Jersey City, on October 7, pleaded guilty in the First District Court of Jer- sey City to a charge of practicing medicine with- out a license and paid the penalty. Aino S. Mateinheimo, of Jersey City, on October 7, pleaded guilty in the First District Court of Jersey City to a charge of practicing medicine without a license and paid the penalty. Eugene Gebauer, of Newark, who was prac- ticing electrotherapy and hydrotherapy, was found guilty of practicing medicine without a license, by the Judge of the First District Court of New- ark, on October 8. He refused to pay the penalty and was committed to jail for 5 days. Nicklos N. Barron, of Newark, who prescribed medicine to be used both externally and internally, was found guilty on October 20, by the Judge of the Second District Court of Newark, of practicing medicine without a license and paid the penalty. Abram Taub, druggist, of Pompton Plains, was found guilty of practicing medicine without a li- cense on October 21, by the Judge of the Paterson District Court. William Miles, of Atlantic City, on October 24, paid the penalty for practicing medicine without a license. Solomon Boxer, druggist, of Ventnor, was found guilty on October 29, by the Judge of the Atlantic City District Court, of practicing medicine with- out a license. The defendant had a dffiloma in his drug store showing that he was a graduate of a college of naturopathy, but prescribed drugs for his patients. Frieda Korte, of Atlantic City, who was giving elec- tric treatments and colonic irrigations, was found guilty by the Judge of the Atlantic City District Court, on a charge of practicing medicine without a license. This was the third time that Mrs. Korte had been convicted and as she was unable to pay the penalty, she was committed for 60 days. George Lezenby, Jr., of Atlantic City, a naturo- path, was found guilty on October 29, of practic- ing medicine without a license, by the Judge of the Atlantic City District Court. He failed to ap- pear in Court and the Judge ordered him com- mitted to jail for 60 days, but when the commit- ment was served he paid the penalty. Charles Schaefer, Sr., of Oaklyn, in October, paid the penalty for practicing medicine without a li- cense. Charles Schaefer, Jr., of Oaklyn, in October, paid the penalty for practicing medicine without a li- cense. Charles S. Newell, of Merchantville, a naturo- path, paid the penalty on November 5, for prac- ticing medicine without a license. Ehrgott W. Gebhardt, of Merchantville, a drug- gist, paid the penalty on November 5, for practic- ing medicine without a license. COUNCILLOR DISTRICT MEETING (A letter from L. Cook Osmun, M.D.) The first Councillor District Meeting of the First Councillor District will be held on Thurs- day evening, February 12, 1931, in the Academy of Medicine, Newark. The main address will be €4 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 by Dr. W. H. Ross, of Brentwood, L. I., and we are planning to make this a large affair. THE WAI/I WHITMAN To the Editor: The American Medical Associa- tion will hold its annual meeting in Philadelphia June 8-12, 1931, and I am writing that you may announce throughout the state the convenience and desirability of stopping at THE WALT WHITMAN during the period of that meeting. As you know, we are but 10 minutes from the center of Philadelphia — busses stopping at our doors at all times. ‘A New Jersey hotel for New Jerseymen”. Sincereley yours, Chas. F, Krapp, Manager. Current Events MINUTES OF THE WELFARE COMMITTEE Trenton, New Jersey, November 9, 1930. Pursuant to call, regularly issued under author- ization of the President of the Medical Society of New Jersey. Dr. George N. J. Sommer, the first meeting of the newly appointed Welfare Commit- tee of the State Medical Society was held at the Stacy-Trent Hotel, Sunday, November 9, 1930. The meeting was called to order by President Sommer, who anounced that the objects of the meeting would be, first, to organize by election of a chairman, and then to transact any business pertaining to the winter’s program. Roll call disclosed the following members pres- ent: Coleman, A. H.; Conaway, Costill, Dandois, Davis, Ely, Green, Haussling, Hunter, Lippincott, McBride, McMahon, Morrison, Morrow, Nafey, North, Schauffler, Schlichter, Sewall, Sherman, Sommer, Tracy. Excuses were received from Drs. Clayton, Donohoe, D. Leo Haggerty, Londrigan and Ward. Vice-Presidents John F. Hagerty, and Quigley were present by invitation, and Drs. Kel- ley and McGuire were present from the State Board of Medical Examiners. The President called for nominations for the chairmanship and Dr. A. H. Lippincott was nom- inated and elected by unanimous vote. The Presi- dent thereupon called Dr. Lippincott to the chair. The Executive Secretary presented the following report: Report of the Executive Secretary to the Wel- fare Committee The Executive Secretary has at the moment only a short report to submit. The work of his office has proceeded in routine manner during the sum- mer, and at present everything is progressing smoothly and satisfactorily. The public educa- tional program will be continued this winter as heretofore, and we have reason to believe that ra- dio broadcasting will be conducted under the aus- pices of 5 county medical societies in whose ter- ritory proper facilities exist; to wit: Atlantic, Ber- gen, Essex, Hudson and Monmouth. The Field Secretary, Mrs. Taneyhill, is carrying a program this year that is even heavier than through pre- vious seasons. With the kindly assistance of the State Board of Education, she has arranged to ad- dress nearly all the school organizations of the state, stressing particularly the importance of mental hygiene, but presenting also on occasion the other lectures of her series. It is early to predict anything about the ap- proaching General Assembly of New Jersey, but the election returns and certain information that has leaked out from political headquarters per- mit us to draw some inferences. In all proba- bility, the next State Senate will be in the hands of our friends; that is to say, that Senator Wol- ber, who has always been cooperative, is said to be slated for the post of President of the Senate; Senator McAllister, of Cumberland, is to be the Re- publican Senate Floor Leader; and our very good and reliable friend, Dr. Blase Cole, is to be the Democratic Senate Floor Leader. If those selec- tions are confirmed we may feel reasonably safe as regards the Senate attitude toward public health legislation. In the House of Assembly, the situa- tion is less favorable. The Republican slate is said to be — Wise, of Passaic County, for Speaker, and Otto, of Union County, for Floor Leader; the first named is a cultist of variegated hue and we need expect no favors at his hands. At the Annual Meeting of the State Society, a resolution was adopted upon motion of Dr. Mor- rison, seconded by Dr. Quigley, that the Welfare Committee be requested to consider the necessity ior or advisability of securing legislation to con- trol or prevent the employment of unlicensed physicians by municipal, county and state institu- tions. That request is hereby respectfully directed to your attention. We have not as yet, of course, any specific knowledge of bills to be introduced into the Gen- eral Assembly but experience leads us to expect the usual crop of objectionable medical bills. The Surgery Control Bill that was under consideration at the Legislatures of 1929 and 1930 is more than likely to make a reappearance. The Welfare Com- mittee of last year left further consideration of that question in the hands of a special committee composed of Drs. John Hagerty, W. G. Schauffler, and Joseph G. Coleman. The special committee on the Hospital Lien Law, under the chairman- ship of Dr. Londrigan, accomplished the greater part of its task last year but was held over to con- sider whether further action in the future is de- sirable. There is no other unfinished business. Respectfuly submitted, Henry O. Reik, M.D., Secretary, Welfare Committee. At the suggestion of the Chairman, the report was accepted and ordered to be placed on file. At the request of the President, Dr. Sommer, the Executive Secretary presented a communica- tion from the Mercantile Finance Corporation of New Jersey, with offices at 32 E. Hanover Street, Trenton, which, in effect, set forth a plan for the collection of physicians’ bad accounts, and for the loan of money to patients for the payment of medi- cal bills or for the payment of prospective sur- gical procedures. Dr. Reik called attention to the fact that a sim- ilar proposition, offered by the Gilbert Acceptance Corporation, of Newark, had been rejected last year by the Welfare Committee after a very thorough investigation by the Secretary and, later, by a special committee. Dr. Sommer stated that he knew nothing about the proposition and presented it only because it had come to him officially. Dr. North remarked that he had seen a copy of the offer, had read it carefully, and did not con- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY sider it worthy of endorsement by the medical pro- fession. Upon motion of Dr. McBride, the committee voted unanimously to decline further considera- tion of the proposition. At the request of Dr. Morrison, the Executive Secretary read a letter z’eceived from Dr. Law- rence Greeley Brown, of Elizabeth, N. J., complain- ing about the manner in which the Medical Bill Adjustment Committee of Essex County had acted in reference to settlement of a professional ac- count rendered to the Aetna Insurance Company for services to an injured man. After some discussion, it was decided that this matter should be referred to the Essex County Medical Society because the complaint dealt with the acts of a, committee in that district. Quoting from the Transactions of the Medical Society of New Jersey in annual session at Atlantic City June 1930, the Executive Secretary called at- tention to action taken by the House of Delegates, upon motion of Dr Morrison, seconded by Dr. Quigley (Transactions, page 42), .calling upon the Welfare Committee to consider what action should be taken with reference to the employment of un- licensed physicians by municipal, county and state institutions. After discussion, participated in by Drs. Kelley, Coleman, Costill, McGuire, Nafey and Morrow, Dr. Morrison moved that this matter be referred to a special subcommittee, to act in cooperation with Drs. McGuire and Kelley, of the State Board of Medical Examiners, for investigation of this ques- tion and later report to the Welfare Committee. The motion was adopted and the Chairman ap- pointed the committee as follows: J. Bennett Mor- rison, Chairman; R. H. M. Davis and Herbert W. Nafey. Dr. McBride called attention to the fact that during his presidency of the State Society he had forwarded to the Governor of the state of New Jersey the names of 3 physicians from whom the Governor might select an appointee for the State Board of Medical Examiners to fill the vacancy which would occur at the expiration of Dr. Char- les B. Kelley’s term, and stated that up to the present time the Governor has failed to act. He felt that the Medical Society is not being accorded proper respect and that the Governor is failing to perform his duty. Upon motion of Dr. Schauffler, it was decided to request the Chairman of the Board of Trustees to call Governor Larson’s attention to this ques- tion again, and to support Dr. McBride in his ef- forts to secure official action. Both the Executive Secretary, and the Secretary of the Board of Medical Examiners, called the Welfare Committee’s attention to newspaper re- ports of the Abell Legislative Committee’s pro- posal to transfer the work of the Medical Exam- ining Board, and other similar bodies, to the State Board of Education. After discussion by Drs. McGuire, Schauffler, North, Morrison and Schlichter, a motion was of- fered by Dr. Schlichter that a committee of 5 be appointed to consider the Abell Committee’s report and to later advise the Welfare Committee what action might be advisable. Dr. McGuire offered as an amendment that the proposed committee be instructed to confer with the Board of Medical Examiners and other sim- ilar groups concerned in the proposed change. Dr. Schlichter accepted the amendment and the amended motion was duly adopted. The Chairman appointed the following commit- tee: Andrew F. McBride, Chairman; Charles H. 65 Schlichter, Henry B. Costill, W. G. Schauffler, and T. B. Lee. Dr. Kelley reported upon the present status of osteopathy and chiropractic in New Jersey, say- ing that he did not believe either of these groups would attempt to secure special legislation this year but that he anticipated an effort on the part of the naturopaths to procure special' privileges. Dr. John Hager ty, as Chairman of the subcom- mittee on the Surgery Bill, stated that his com- mittee would report at a later meeting. The Executive Secretary presented a document prepared by Dr. Morrison in explanation of the State Society work and the manner in which the Society’s funds are expended, and recommended that this be printed in the form of booklet pre- viously used with reference to auxiliary matters and in explanation of cultism, and that these book- lets be distributed for the edification of members of the State Society and for the use of officers of county societies in collecting dues and in pro- curing new members. A motion was duly passed authorizing publica- tion and distribution as recommended. The meeting then adjourned. Henry O. Reik, M.D , Secretary, Welfare Committee. SPECIAL MEETING A special meeting of the Welfare Committee was held at the 'Stacy -Trent Hotel, Sunday, De- cember 14, at 3 p. m., with the Chairman. Dr. A. Haines Lippincott, presiding. The following members answered to roll call: Bloom, Clayton, A. H. Coleman, J. G. Coleman, Conaway, Dandois, Davis, Donohoe, Ely, Green, D. Leo Haggerty, Hunter, Larkey, Lippincott, Londri- gan, McBride, McMahon, Morrill, Morrison, Mul- ford, Nafey, North, Schauffler, Schlichter, Sewall, Sherman, Sommer and Tracy. The following sent excuses: Brown, Haussling and Lee. The following invited guests were present: John F. Hagerty, Paul M. Mecray and James J. McGuire. The Chairman called for the report of the Ex- ecutive Secretary, and Dr. Reik asked permission to present his report in sections in order that the first section might be acted upon as promptly as possible because some members interested in that portion of his report would want to be excused at 3.30 p. m. to attend another meeting. Report of the Executive Secretary (Section 1) There are several matters of interest to be pre- sented to the committee today, but inasmuch as there is to be another meeting at 3.30 p. m„ which must be attended by some of our members, a con- ference of representatives of organizations affected by proposed legislation growing out of the Abell Commission’s report, it seems best to list that subject first. Since the last meeting of the Welfare Committee, on November 9, the Abell report has been made public and several legisative acts designed to con- vert that commission’s recommendations into law have been introduced into the General Assembly. On Saturday, November 29, Dr. McBride and the Executive Secretary traveled to Morristown for an interview with Senator Abell, the results of which were quite satisfactory. On December 1, Senate Bill 304 was introduced, and the 3 bills which affect the State Board of Medical Examin- ers have since been made available for study. S. 260 provides for establishment of a centralized 66 JOURNAL OK THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 control and uniform system of accounting for the money received and expended by the state. S. 262 provides for an improved budgeting plan to take the place of the existing unsatisfactory method. S. 304 is a special act designed to bring all of the Boards of professional examination and licen- sure under a central bureau in the State Depart- ment of Education. It is the last named bill which has caused most public discussion, though objec- tion has also been made to S. 262. On Sunday, De- cember 7, representatives from several of the pro- fessions and Boards met in Trenton to confer with our own subcommittee under the chairmanship of Dr. McBride; the other groups present including particularly the dentists, pharmacists, and under- takers and embalmers. On Thursday, December 11, at a public hearing on S. 262, we were represented by President Sommer. Announcement has been made that a public hearing will be given Tuesday, December 16, on S. 304. At this point I wish to ask your consideration of 2 or 3 possible danger spots in the manner of dealing with this proposed legislation. First, per- mit me to warn against a too intimate alliance with the organizations that are opposing this legisla- tion. That phrase may sound queer, coming from me, in view of my previous efforts in the direc- tion of cooperation. It was I, for instance, who 3 years ago brought about the cooperative re- lationship with the pharmacists. But, please keep this in mind — that while I have always advocated cooperation, I have never recommended amalga- mation. We may, indeed we should, confer with the other organizations, but we should be ex- tremely careful to avoid responsibility for actions they may take, and extremely cautious about entering into any conference that may in- volve us in an obligation to support a ma- jority decision. That is a very important point to keep in mind. Already, newspaper articles have appeared from one of those groups that our so- ciety certainly could not endorse. I am informed that at the public hearing last Thursday some of those groups were represented by special agents, attorneys, and ex-members of the legislature. I trust this society will not be led into joining in such a procedure or into fol- lowing that example. It would be derogatory to the dignity of our profession and it would be in- jurious to the standing we have acquired through 6 years of following a different policy. Incidentally, such methods rarely, if ever, accomplish the in- tended purpose, and they do constitute a waste of money. Members of this group present today can better represent you and accomplish more satisfactory results than can any attorney or paid lobbyist in the United States. Further, permit me to express the opinion that we are in grave danger of being swept into a false position through the influence of mob psy- chology. The appearance of these legislative bills, indeed the preceding newspaper stories about what the Abell report would contain, planted in our minds a fear that something terrible was going to happen. That fear has grown to the point where we are in danger of acting unreasonably. I have heard much talk about these bills but most of it has been irrelevant, based upon fear rather than study of the bills, and some of it has en- tirely misrepresented the apparent intent and the actual wording of the bill. I have heard it argued that these bills propose abolition of the Boards of Examiners, substitution of examinations by per- sons incapable of conducting appropriate ex- aminations, the employment of an immense force of adjunct employees to carry on the work, and the application of funds properly received by the Boards to State work other than that heretofore carried on by the Boards. There is not a word in either of the laws to justify any of those criticisms. I am not a prophet and I cannot predict with cer- tainty what will happen if those laws are enacted, but that is not the question before us at the moment; the question calling for our first con- sideration is — what do these bills propose? I do not see how the medical profession can consistently oppose bills 260 and 262, for they offer to the state exactly what all good citizens have been demanding whenever the wastefulness or the dishonesty of state government has been under discussion. S. 262, to which exception has been noted, proposes for the state exactly what this society has had for years and what it held so precious as to rewrite into its new Constitution and By-Laws. The budget system and central control of all monies is one of the cardinal prin- ciples of the business conduct of this society. What does S. 304 say? Stripped of all excess verbiage, which for some inexplicable reason is made a part of all legislative acts, it provides: (1) For creation of a bureau within the De- partment of Education “for the centralization of records’’ and “for the administration of the financial operations of the several examining and licensing Boards”, at the same time “preserving the entity and identity” of such Boards, and that all monies received by such Boards “shall be paid into the State Treasury” and that all expenditures of said Boards shall be in accord with the state budgeting system. (2) Authority is conferred upon the new bureau, specificially, “to manage and regulate the financial operations of the several Boards”; to “receive and pay over to the State Treasury all monies col- lected by the Boards”; and to issue licenses and certificates of registration when and as approved by the said Boards”. (3) “Requests for appropriations shall be sub- mitted by said Boards to the bureau”, and the bureau shall pass approved requests to the Budget Committee, which in turn submits a report to the Legislature as a basis for the appropriation of funds, “to the end that expenses for maintenance, operation and administration of said Boards shall be appropriated from the funds collected by the Boards or from the free treasury funds of the state”. (4) “Nothing contained in this act shall be construed to conflict with the examining, regu- lating and general supervisory functions of the State Boards.” I am unable to detect anything very alarming in those provisions. I would suggest 3 slight change?, in the form of amendments: 1 believe that administration of the bureau might better rest with the Board of Regents than with the Commissioner of Education; that is, something comparable to the New Y'ork plan. Secondly, a verbal change in the provision for appropriations might be made so as to assure annual appropria- tion of a sum not less than that of the receipts of the Board. At a meeting of the Tristate Medical Conference one week ago, I reported our concern over this pending legislation, and the President of the Pennsylvania Society, Dr. Ross V. Patter- son, Dean of Jefferson Medical College, and who is better informed than most of us concerning medical education and Medical Licensing Boards, stated that Pennsylvania now has practically the same legal provisions and that he would advise us to accept the proposed laws because he believes they will work out to our advantage. The ex- periences of New York and Pennsylvania consti- tute the answer to some of the protests that this J-n„ 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY G 7 proposed legislation is unique and impracticable. Thirdly, I would insist that the State Bar Exam- ining Board and the Realtors’ Board be included in the law. The most pronounced criticisms of the Abell Commission plan seem not to be based upon the proposed laws themselves but upon suspicion and fear of how' such laws may be enforced. That is a criticism of the American political system rather than of these special acts, and I think we should study these acts carefully before assuming a pub- lic stand in opposition. The Chairman: The first section of Dr. Reik’s report is before you for action. Dr. McBride: I am opposed to the transfer of these licensing Boards to the Department of Edu- cation for the reason that I am afraid such trans- fer wTill enable, or will result in, bringing these matters under control of politicians. As to sub- stituting the Board of Regents for the Commis- sioner of Education, I would like first to know something more than I do now about the Board of Regents. As to S. 262, I think we should insist upon a re- turn to our Board of all the monies turned into the Treasury by the Board. That amendment, sug- gested by Dr. Reik, is a good one. Dr. Schauffler: I wonder if Dr. Sommer would like to tell us something about the hearing on 262 last Thursday. Dr. Sommer: A hearing was held on that bill last Thursday and I attended along with repre- sentatives of the dental and pharmaceutical asso- ciations, as arranged at the conference last Sun- day. It seems that there is to be another hear- ing on that bill, for I have received a message stating that S. 262 and S. 304 will be considered further at the hearing announced for Tuesday, December 16. The main opposition to 262, as developed last Thursday, was on the score of “dedicated funds” Everybody wanted to know what dedicated funds meant. The school teachers, for instance, feared that might interfere vrith their pension fund, and I noticed that their attorney, Mr. McCarter, wanted an assurance written into the bill to make it clear that such fund would not be interfered with. Dr. Liva spoke for the Medical Examining Board and the medical profession and Dr. Forsythe, of this city, spoke for the dentists. The conference committee, of which I am a part, came to the con- clusion that it would be wise to have an attorney’s opinion on some parts of these bills and has asked - Mr. McCarter to interpret those bills in so far as they relate to the medical profession. Senator Richards, who did most of the , cross questioning, tried to keep away from any promise guaranteeing a return to the Boards of their own funds. Dr. McBride: We had a meeting of the Passaic County Medical Society last week and passed reso- lutions opposing S. 262 and I will ask Dr. Reik to read those resolutions. Dr. Reik: Several of the county societies have passed such resolutions and I have been informed of such action by the Atlantic, Monmouth and Passaic County Societies and by the Physicians’ Association of Woodbury. The Passaic County resolutions, asked for by Dr. McBride, are as fol- lows : “We the members of the Passaic County Medi- cal Society, respectfully request that you oppose Senate Bill number 262 in its present form. We contend that unless the bill is amended to make mandatory an annual appropriation equal to the amount of money collected by the State Board of Medical Examiners during the year the cause of public health will be endangered. This money is necessary for the proper execu- tion of the work engaged in by the State Board of Medical Examiners in the interest of public health. We feel that this money should be avail- able to the Board without any uncertainty of ap- propriation. We know that it has always been the desire and wish of the State Board of Medical Examin- ers to have its accounts audited by the proper au- thorities and we heartily endorse this principle.” Dr. Morrison: I move that we endorse and adopt the resolutions sent by the Passaic County Medi- cal Society. This motion was seconded and unanimously adopted. Dr. Morrill: I understand that action applies only to S. 262. Dr. Morrison: Yes. Now as to S. 304, I feel that we have perhaps not sufficiently studied that bill to justify flat opposition. I have read the act carefully and it seems to me to guarantee keeping the examining and licensing in the hands of the respective Boards; it doesn’t propose to do any- thing to such Boards except to govern their money affairs. I am inclined to think it would be a good thing to approve this legislation if we can secure the amendments that have been suggested. Dr. Hunter: I would like to ask how the Board of Regents is constructed, whether by appointment or by election, and whether anybody here knows the members of that Board? Dr. Schauffler: I know the President of that Board very well indeed, and am sure that Mr. Jeffers is a thoroughly trustworthy individual. Dr. Morrison: I would like to say that our limit- ed experience with the Board fully justifies that recommendation. When the Chairman of our Post-Graduate Instruction Committee and the Ex- ecutive Secretary had occasion to confer with the Board of Regents regarding plans of the State Medical Society and Rutgers University, Mr. Jef- fers treated them with the utmost courtesy, showed great interest in our educational work, and prom- ised his hearty support. I have thought for sev- eral years that this society should endeavor to secure an association with the Board of Regents similar to that existing in New York. Dr. Morrill: I think that Dr. Reik and Dr. Mor- rison have hit the nail pretty squarely on the head in regard to these bills, namely, that the greatest objection is to placing the Boards under the con- trol of the Commissioner of Education. Such a change as is proposed would bring these Boards under the control of one individual, and that indi- vidual filling a position by political appointment. If the Board of Regents could be substituted, for the Commissioner of Education, the bill would be vastly improved. In fact, the bill does not other- wise read badly. Dr. Schlicter: I also think this substitute would be a good one and for the reasons just expressed by Dr. Morrill. I am skeptical about giving too much power to the State Board of Education, and I say that because there seems to have been lately 68 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 a movement all over the country, on the part of these Boards, seeking for more power. Dr. Morrison : I move that the suggested amend- ment, providing that the Board of Regents shall be substituted for the Commissioner of Education, in S. 304, be endorsed. The motion was seconded, but was defeated by vote of the committee, after lengthy discussion of the bill and its possible effects by Drs. McGuire, Reik, North, Hagerty, Lippincott, Hunter and Davis. Dr. Londrigan moved that the Welfare Committee express its opposition to the entire bill — S. 304. The motion was seconded and carried. Report of the Executive Secretary (Section 2) Next, Mr. Chairman, I would like to report that in response to a call from the Legislative Bureau of the American Medical Association, I have filed with each of the Senators and Congressional Rep- resentatives from New Jersey protests against 2 bills now under consideration by Congress (1) An Antivivisection Bill applicable to the District of Columbia but announcedly intended as an enter- ing wedge for similar legislation relating to the states; (2) the Jones-Cooper Bill which consti- tutes an attempt to reenact the old Sheppard- Towner law. As indicating our relationship with legislators, resulting from the plan of direct per- sonal appeal in the name of the State Society, it will interest you to know that out of our delegation of 14 members written to, we received prompt an- swers from 10 ; 1 of them replying by telegram, and all of them expressing thanks for the infor- mation supplied. Dr. Dippincott: I think we should endorse the the Secretary’s action in this matter, and trust somebody will so move. Dr. Conaway offered a motion endorsing the Secretary’s action and instructing him to continue opposition to the Antivivisection and the Jones- Cooper Bills. The motion was seconded and unanimously adopted. Executive Secretary’s Report (Section 3) At one of our sessions last year, we had under consideration a form of health department blank to be used by physicians in recording information required by law to be made available to the Crippled Children’s Division of the State Rehabil- itation Commission at that time objections were made to the several forms under consideration. On December 4, Mr. Buch, the Chairman of that Commission, called to see me for the purpose of submitting a new record form. He has endeavored to reduce the requirements to the lowest limit, and the present proposition is to utilize the customary Health Department blanks for births and still-births, adding to such books of blanks, in the front portion, several blank forms to be used when necessary. On the regular blanks would be printed a line directing attention to the necessity for filling the special blanks whenever there exist deformities that should be reported. The special blank provides for recording the name, address, date of birth, type of deformity, whether under treatment or referred to other physicians or surgeons, and the signature of the attending physician. The Commission and the Health De- partment would like to have immediate considera- tion of this matter so that if approved the certi- ficates can be prepared for new blanks about to be ordered by the Department. Dr. Ely: As Dr. Reik has stated, this matter was before us a year or more ago and it seemed impos- sible then to agree upon a satisfactory method of making these records. I move that we approve of the plan he has submitted today. The motion was seconded and adopted. Report of Executive Secretary (Section 4) The National Bureau of Economic Research, in letters dated December 2, appealed to Drs. Sommer and Morrison for information regarding medical care on an insurance or contract basis, in New Jersey. The Bureau asks: “(1) Do you know of any hospitals or group clinics in your state that are offering medical service to individuals or to employers (for the benefit of their employees) on a contract basis? The essence of the contract is of course an agreement on the part of the hospi- tal or clinic to furnish a certain type of service during a stipulated period of time in return for a fixed fee paid by the contract holder. (2) Do you know of any corporations or associations of- fering such service and arranging with medical practitioners and hospitals to give the medical service?” A proper response to this request would neces- sitate an investigation that would involve consider- able time and labor for some person or committee, and we submit the proposition for consideration. Dr. Haggerty: I move the appoinment of a sub- committee to consider this question and report later to the Welfare Committee. The motion was seconded and adopted. The chair appointed Drs. D. Leo Haggerty, Chairman ; Francis R. Haussling and Samuel A. Cosgrove. Report of Executive Secretary (Section 5) At the last annual meeting of the State Medical Society a great deal of time was devoted in the general sessions and in sessions of the Section on Ophthalmology, to discussion of the Workmen’s Compensation Laws. The December issue of the Journal carries one of the most instructive dis- cussions of that subject that we have seen, and the January issue will carry the papers and dis- cussions that were associated with the appear- ance at our convention of the medical represen- tative of one of the large insurance carriers. Our neighbor states, with compensation laws more or less like our own, and with problems of similar character to those that have arisen in this state, have also been giving attention to this mat- ter. The New York State Journal of Medicine of November 15, 1930, presents us with an agreement that has been made between the Medical Society and the Compensation Carriers — an agreement which seems to offer a solution for most of the difficulties complained of. I have a copy of that agreement at hand, but I would not claim to be competent to say that it is applicable in all re- spects to conditions in New Jersey. I would like to suggest that it be immediately taken under consideration by some one or some committee competent to advise the Welfare Committee and the State Society with reference to this matter. Dr. Morrison: This is a matter that deeply con- cerns the Medical Society of New Jersey and I move the appointment of a subcommittee of 5 to study the documents that Dr. Reik is prepared Jan., 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 69 to present, and to advise us as to their application to New Jersey conditions. Dr. John Hagerty: In seconding that motion I want to say that I attended a meeting in New- ark recently at which this same matter was dis- cussed and I think that the New York agreement is applicable to most of the conditions existing here with reference to our Workmen’s Compensa- tion Act. I will be glad to serve on that committee if you think I can be of any assistance. Dr. Lippincott: It is so unusual to have anyone volunteer for work that I think we can assure you, Dr. Hagerty, your offer will be accepted. The motion was then unanimously adopted. The chair appointed Drs. J. Bennett Morrison, Chair- man; John F. Hagerty, H. B. Costill, Millard F. Sewall and B. C. McMahon. Dr.Reik: During the last 2 legislative sessions, Dr. Leo Haggerty has looked after certain affairs for the Welfare Committee, particularly by keep- ing us informed of the exact status of legislation pending in the General Assembly. Being required to subscribe to the New Jersey Legislative News, he has expended for such information the sum of $25, for which amount he should be reimbursed. A motion duly made and seconded authorizing payment of this bill. Dr. Morrison: I would like the Welfare Com- mittee to submit to the House of Delegates of the Medical Society of New Jersey, at its meeting in June next, a request that this committee be given permission to draft an amendment to the Medical Practice Act giving us power similar to the Griev- ance Committee, provided for in the New York law. Dr. Morrison’s motion was seconded and unani- mously adopted. The meeting then adjourned. Respectfully submitted, Henry O. Reik, M.D., Secretary. Woman’s Auxiliary THE SOCIETY FOR THE RELIEF OP WIDOWS AND ORPHANS OF MEDICAL MEN OF NEW JERSEY Edward J. Ill, M.D. (An address delivered before the Woman’s Aux- iliary of the New Jersey State Medical Society at the Annual Meeting June 12, 1930.) I am thankful to be able to present to you some facts which should of necessity interest you. If it is not for your personal benefit, you should be aware how many doctors leave their families in a destitute condition and how our society has been able to relieve much real distress. The Society for the Relief of Widows and Or- phans of Medical Men of New Jersey has been in existence for 40 years. It has 500 members. At the annual meeting on May 14, the Treasurer re- ported a Permanent Fund of $44,930. The income from the Fund amounted to $2316.63. This in- come may be distributed to such widows and or- phans as in the opinion of the trustees is thought wise. The trustees wish to help such as are in need. It is not considered a charity by the trus- tees but a right to which such widows and or- phans are entitled. I am asking you now to present to me the names of such widows and orphans of members, who are in need, so that the trustees may take such ac- tion as they think wise to give some relief. It has been most difficult to get the names of such as are in need. A false modesty, or let us call it pride, may be at the bottom. Let us remember that the needy have a right to request aid. During the past year we have distributed $850 to such widows. No doubt we could do better if we knew to whom to send help. It may interest you to know of a few instances of which the trustees have been able to learn and where they have given relief. There is Mrs. S., the widow of a very active former member of the State Society. He left her with an income of less than $15 a week, and a hopeful son of grammar school age. With the little help we could give her, being an energetic woman, she got along. Suddenly her son, after leaving college, got sick with an incurable disease. Then there is Mrs. W., left with 3 little children and no help. Mrs. N. was an old lady when she became a widow. We helped to get her into an old ladies home. Mrs. V. was left with 6 children ranging from 2 to 15 years of age, after her husband had died from pulmonary phthisis of some years standing and during which time their little savings had dwindled to almost nothing. Mrs. T. had a husband, who had been sick and helpless with chronic arthritis. For years he earn- ed nothing, and we were glad to make him a loan while he was living and then helped the widow until such time as she could look out for herself. Mrs. G. retired to the country. Two of her half -grown-up children got sick with phthisis. We were glad to help her. Mrs. H. was left with 5 little children after Doc- tor H. died from a long illness of heart trouble. She certainly needed our help. Dr. E. left a widow, well advanced in years. He was an old man when he died. He had lost all during his declining years when sickness prevented following his occupation. I might go on relating many more deplorable instances. In 9 years we have distributed but $4400. During this time we have also made loans to sick doctors to the amount of $720. This, of course, came back to us from the death benefits but was soon returned to the widows as a gift. You will be surprised to learn how many widows are in immediate need of funds after the doctor’s death. With the usual poor business ability of our profession, no provision has been made for any immediate help. Thus, a very busy surgeon died within the year. There was not enough money to pay the grocer. Our check came as a great relief and we were glad to be able to send it within a few days of the doctor’s death. I am showing you what amount we have paid out annually during the past 11 years. Amount paid heirs of members each fiscal year ending May 1: 1920, $4250.25; 1921, $1197.75; 1922, $3856.50; 1923, $2430.50; 1924, $3956.00; 1925, $4317.25; 1926, $5467.75; 1927, $2126.75; 1928, $3617.25; 1929, $5633.75; 1930, $5307.75. If your husband is not a member please pre- vail on his becoming one. Please correspond with me or the Secretary, Dr. Wm. D. Minningham, 18 Hedden Terrace, Newark, N. J. I want to thank you for giving me a hearing 70 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 and am open to any questions you may want to put before us. I also want to express my appreciation to your President, Mrs. Hunter, as well as Mrs. Clark, Chairman of your Program Committee for their kindness to me. WINNING THEM OVER At a meeting of the Secretaries of County Branches of the Wisconsin Medical Society, held at Milwaukee, March 1, 1930, the President of the State Society, Dr. F. J. Gaenslen, said: “I am glad to see that one of the subjects on the program is that of the Woman’s Auxiliary. While I was not keen about that some months ago, the more I think of it, the more I feel it is going to be a powerful influence in the formation of public opinion regarding matters pertaining to medicine and to public health in general.” STATE AUXILIARY The Woman's Auxiliary to the Medical Society of New .Jersey will hold a luncheon meeting at the Stacy-Trent Hotel, in Trenton, on Monday, Jan- uary 12, at 1 p. m. Mrs. Walter Jackson Free- man, of Philadelphia, will be the guest of honor and there will be guests from the neighboring states of Pennsylvania and Delaware. Mrs. Free- man will outline plans for the meeting of the National Auxiliary to be held during the session of the American Medical Association in Phila- delphia from June 8 to June 12. She will tell the State Auxiliary how much depends upon it in the line of hospitality. Mrs. John Nevin, the President, will preside and she will help formulate a program for our activities during the meeting of our State Society at Asbury Park the first week in June. Please send acceptances promptly to Mrs. George N. J. Sommer, 120 West State Street, Trenton, New Jersey. Bergen County Reported by Mrs. Michael Sarla The regular monthly meeting of the Woman’s Auxiliary to the Bergen County Medical Society was held in the form of a luncheon on December 9, at ‘‘Ye Chestnut Tea House” in Bogota with 23 members present. Mr. and Mrs. B. C. Wooster, of the County Board of Education, were our guest speakers. Bridge was played during the remainder of the afternoon. Gloucester County Reported by Mrs. Henry B. Diverty The Woman’s Auxiliary to the Gloucester County Medical Society had luncheon at the Wood- bury Country Club November 17 at 1 p. m., under the auspices of the American Homes Department of the Women’s Clubs, to hear Dr. Ellen Potter, Director of Medicine in the State Department of Institutions of New Jersey. On November 20 the Auxiliary met at the Wood- bury Country Club at the same hour of the doc- tor’s meeting, the president, Mrs. E. Downs, in the chair: 14 members and guests were present. Following the business meeting Mrs. James Hun- 1 ter, Jr., of Westville, ex-president of the State j Auxiliary, gave a detailed report of her trip to the Johnstown, Pa., Convention the week of Oc- j tober G and stressed the efficiency with which it 3 was conducted. She also reported as 1 of 4 vice- chairmen on the State Program Committee for entertainment of the guests of A. M. A. Conven- J tion to be held June 8 to 12, 1931, in Philadelphia. Plans are well under way, under the very effi- cient leadership of Mrs. Freeman, of Philadelphia. After adjournment the doctors and Auxiliary were I ushered into the dining room where a wonderful | repast was served by our new chef at the Wood- 1 bury Country Club. Hudson County Reported by Anne Hetherington The regular meeting of the Woman’s Auxiliary I to the Hudson County Medical Society was held on I November 14 in the Jersey City Y. W. C. A. Announcement was made that on January 21, 1 in the Stacy-Trent Hotel at Trenton, an open 1 executive meeting will be held, followed by a t luncheon at which the president, Mrs. John Nevin, 1 hopes to see a large representation from Hudson I County. The event of the day was a lecture on “Adult- I Child Psychology” by Miss Flack, member of the I Child Development Institute of Columbia Uni- | versity. Miss Flack commended those present for their interest in her subject, which is engaging - almost universal attention. She explained the urg- I ent need of a new psychology to solve the prob- I lems of the modern parent and child since the whole fabric of living has changed in the last 10 I years. Instead of the old-fashioned home with its I garden and attic play-grounds, we have the small I apartment where the mother has a 24 hour con- fl tact with the child. Irritability is the natural re- 1 suit of such emotional strain. Perhaps George I Bernard Shaw had an over-burdened mother in mind when he made the statement that the only autocracy left in the world today is the home, I where the worst tempered member always rules. 1 It is the purpose of the newer methods to lessen difficulties of that hardest but most important job in the world — raising a family. Psychologists are opening the way to a better understanding of child behaviorism and many believe environment to be the strongest influence in human training. Scien- tists differ on this score, some declaring the adult to be 80% the result of heredity and only . 20% of environment, but since not much can be done with heredity any way, the more plastic fac- tor, environment, remains the hope of the race. A social hour was enjoyed after the lecture. The following new members wei'e welcomed: Mrs. O. R. Blanchard and Mrs. E. J. Daly, of Jersey City; Mrs. Joseph Londrigan, Mrs. H. Broesner, Mrs.. J. Rosenkranz and Mrs. W. W. Farr, of Hoboken; Mrs. H. Schwartz, North Ber- gen; Mrs. William Eckert, Union City; Mrs. E. Bailyn, West New York; and Mrs. Charles Larkey* of Bayonne. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 71 County Society Reports ATLANTIC COUNTY John Irvin, M.D., Reporter The regular monthly meeting of the Atlantic County Medical Society was held in the Blue Room of the Chalfonte Hotel on Friday evening, December 12, at 8.30 p. m., with 95 in attendance, including Dr. George N. J. Sommer, President of the State Society, and Dr. J. B. Morrison, Secre- tary of the State 'Society. The minutes of the previous meeting were read by Dr. Joseph IT. Marcus, secretary. Dr. Homer I. Silvers, president, called for re- ports of the various committees. Board of Censors by Dr. Clarence Andrews: The applications of doctors who have just graduated or Who have not been practicing for 12 months will be held over for 12 months. This is no re- flection upon the man himself, but is merely a custom. Public Health and Sanitation by Dr. W. Blair Stewart: The matter of broadcasting was brought up at the last meeting. Dr. Reik has been in- vestigating that subject. A motion was passed that the incoming president appoint a committee to arrange for broadcasting of health talks over WPG. Dr. Stewart spoke of the Abell Bills now before the state legislature to reorganize the state busi- ness and the state budget. Dr. Stewart stated ob- jections of the Board of Medical Examiners and said he would like to see the society vote unani- mously against these bills. Dr. Sommer spoke about S. 262 which pro- vides for putting all state funds in a budget sys- tem, including all funds received from licensing candidates. While the proponents of this bill as- sure us that there will be no difficulty about allowing funds for the prosecution of illegal prac- titioners, there is nothing definite in the bill about this matter. When one deals with politicians one must not take anything for granted. Dr. Darnall also spoke against these bills and urged all who could to be present at a hearing on the bills in Trenton. A motion was unanimously carried that the so- ciety go on record as opposed to Senate bills 262 and 304 and that a copy of the motion be sent to our senator and assemblymen. Dr. Morrison read a paper on the menace of state medicine, explaining its present status and asking all to concern themselves in order that we may find a relation satisfactory to the public and to the profession. Dr. W. P. Conaway spoke about a notice he had received from the Narcotic Department of the Government. This notice stated that if the nar- cotic tax is not paid medical men are subject to a fine of $2000 or jail for 5 years. Previously the fine was 75% of the amount of the tax. He sug- gested that steps be taken to find out what this means. Dr. Stewart replied that he has already written to the authorities for an explanation. Dr. J. H. Marcus read a letter from another col- lection agency which desires to enter into rela- tions with the society. The communication was laid upon the table. A letter of appreciation was received from the Atlantic Visiting Nurses’ Association. Dr. Marcus also spoke about the collection of dues. Out of 130 members, only 35 have paid their dues. The official list closes January 25, and those who are not paid up before that time will not have their names listed and will not re- ceive their Journal. Dr. Silvers introduced the speaker of the even- ing, Dr. John Deaver, who read an interesting paper on “The Acute Abdomen”. Discussion fol- lowed by Drs. Stewart, Senseman, Scanlan, All- man and Deaver. Atlantic City Hospital Staff Joseph H. Marcus, M. D., Secretary The stated monthly meeting of the Atlantic City Hospital Staff was held November 2 8 in the Nurses’ Auditorium, with Dr. David B. Allman presiding. The program presented was that of the Medi- cal Service, Dr. Clarence D. Andrews, Chief, and Dr. Hilton S. Read. Dr. Read presented a survey of the months of August, September and October; 169 patients being admitted, of whom 90 were males and 79 females. Dr. J. V. Reeves, resident physician, reported an interesting case of “Ruptured Abdominal An- eurysm”. C. P., aged 32, male, colored, was ad- mitted complaining of pain in the epigastrium, coughing and vomiting of blood (?). Father died of carcinoma, 5 yr. before, but further than this no hereditary taint discoverable. Onset of trouble 3 days before admission. Went on a “drunk’1’ and stayed under the influence of alcohol for 2 days; then began to feel weak and this weakness was accompanied by distress in the epigastrium. This tormina increased in severity,